Handbook of Interpersonal Violence and Abuse Across the Lifespan: A project of the National Partnership to End Interpersonal Violence Across the Lifespan (NPEIV) 3319899988, 9783319899985

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Robert Geffner · Jacquelyn W. White L. Kevin Hamberger · Alan Rosenbaum Viola Vaughan-Eden · Victor I. Vieth Editors

Handbook of Interpersonal Violence and Abuse Across the Lifespan A project of the National Partnership to End Interpersonal Violence Across the Lifespan (NPEIV)

Handbook of Interpersonal Violence and Abuse Across the Lifespan

Robert Geffner • Jacquelyn W. White • L. Kevin Hamberger • Alan Rosenbaum • Viola Vaughan-Eden • Victor I. Vieth Editors

Handbook of Interpersonal Violence and Abuse Across the Lifespan A project of the National Partnership to End Interpersonal Violence Across the Lifespan (NPEIV)

With 254 Figures and 107 Tables

Editors Robert Geffner Institute on Violence Abuse and Alliant International University San Diego, CA, USA

Jacquelyn W. White Department of Psychology College of Arts and Sciences University of North Carolina at Greensboro Greensboro, NC, USA

L. Kevin Hamberger Department of Family and Community Medicine Medical College of Wisconsin Milwaukee, WI, USA

Alan Rosenbaum Department of Psychology Northern Illinois University DeKalb, IL, USA

Viola Vaughan-Eden Ethelyn R. Strong School of Social Work Norfolk State University Norfolk, VA, USA

Victor I. Vieth Education and Research Zero Abuse Project St. Paul, MN, USA

ISBN 978-3-319-89998-5 ISBN 978-3-319-89999-2 (eBook) ISBN 978-3-319-90000-1 (print and electronic bundle) https://doi.org/10.1007/978-3-319-89999-2 © Springer Nature Switzerland AG 2022 All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG. The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword

When we think of violence, our mind is drawn to an experience we or someone we know has had or to a recent story in the news about a single type of violence, perhaps a mass shooting, domestic violence, or gang activity. However, there are many forms of violence and any of us being quizzed would be hard pressed to name the full set. A subsample includes psychological, sexual and physical child abuse, sexual assault, intimate partner violence, sex and labor trafficking, cyber abuse, hate crimes, neglect, elder abuse, pet abuse, stalking, gang violence, and more. From the standpoint of research, clinical practice, and social services, the many different forms of interpersonal violence have been largely separate areas of work. This is understandable because any one area requires specialized training and understanding to address the challenges. Indeed, we can see from this Handbook of Interpersonal Violence and Abuse Across the Lifespan that each type of interpersonal violence has its own body of knowledge in terms of what is known about the prevalence, risk and protective factors, key moderators, and available interventions, services, and government policies. What has been increasingly recognized is that the very different areas of interpersonal violence have extraordinary commonalities, blur into each other, and often go together. We know now that different types of interpersonal violence and abuse: • Share a common set of factors, especially early in life, that increase or decrease the risk for being a victim or perpetrator of violence • Connect with several individual, interpersonal, social, and cultural issues, including trauma, power and control, oppression, sex and gender, culture and ethnicity, poverty, discrimination, and untoward living conditions, to mention a few • Generate a similar set of deleterious outcomes related to mental and physical health, substance use and abuse, deficits in fundamental psychological processes (e.g., cognition, learning, and memory) and social functioning (e.g., interpersonal relations more generally, job performance), and, if these were not sufficient, increased suicide rates and early death • Reflect common biological assaults, as reflected in problems in brain, hormone, endocrine, and immune functions • Blur into each other so that an individual who is a victim or perpetrator of interpersonal violence at one point in life (e.g., abuse in childhood, bullying in v

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adolescence) is at greatly increased risk for another type of abuse or perpetration later (e.g., date rape, abusing a partner) • Can be altered and that interventions effective in reducing one type of violence often can reduce other types of violence as well • Exert an enormous economic burden resulting from the broad and enduring effects of trauma, victimization, and perpetuation of violence • Converge to reflect an enormous public health and human rights problem that reaches diverse groups, at all ages, and is a source of tragedy and trauma, often lifelong. What is needed is a resource that brings together areas that have been largely separate from the standpoint of research, intervention, services, and policy. The Handbook provides exactly that resource and gives us an up-to date evaluation of individual areas while underscoring the commonalities and interconnections. The editors have produced a work that is massive in scope by including over 400 contributors, over 200 chapters, and comprising 5 volumes. This is a resource without peer in content and scope, but more than that sets the stage of how to view the entire domain of interpersonal violence and abuse. Even with such diversity of topics, there is remarkable coherence in the different contributions. This was achieved in at least four ways. First, the chapters adhere to an overall conceptual focus in which interpersonal violence is elaborated at multiple levels, including individuals, relationships, communities, and society. Second, the chapters provide a developmental perspective that conveys how violence occurs at different ages and stages (infancy, childhood, adolescence, adulthood, and the elderly) and, importantly, how the types of violence and the periods in which they occur are very much related to violence at other stages. Third, multiple influences including biological, psychological, familial, situational, and cultural contexts are included. Finally, the chapters attend to perpetrators and victims of violence including those who are both perpetrators and victims. These unifying levels and foci embrace the intricacies of violence while allowing one to see the overall commonalities in a cohesive way. By integrating multiple sources and types of violence, we can also get a better picture of what is being done and what is needed to improve services. To be sure, many organizations and agencies (government and nongovernment, national and international) are committed to preventing, reducing, and eliminating interpersonal violence and abuse. One such organization, the National Partnership to End Interpersonal Violence Across the Lifespan, has served as the impetus for bringing the large set scholars together to complete this set of volumes. Given these connections and commonalities, the study of violence is inherently collaborative, multidisciplinary, and international. To understand violence and have impact on its amelioration requires many different disciplines, including but not restricted to public health, psychology, social work, education, criminal justice, law and social policy, nursing, and medicine including many of its branches (e.g., psychiatry, pediatrics, emergency medicine). Moreover, there are many stakeholders whose participation is central, including practitioners, advocates and survivors of violence and abuse, healthcare workers, religious and spiritual leaders, government

Foreword

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agents devoted to health, funding agencies, and of course victims and perpetrators. The challenge is harnessing the range of participants. The huge first step is recognizing and documenting the need for integration and showing how integrative interventions can have impact. The Handbook conveys this and more. The volumes are about interpersonal violence and abuse, so the content is not merely academic but focuses on suffering and on a scale that does not lose sight that millions of individuals have been and are being traumatized, permanently injured, and killed. They are individuals with little or no control and often no recourse. The upbeat part is that some of our best scientists and minds, that is, contributors to these volumes, are working in the areas, have made palpable progress in understanding the problem, have developed interventions for treatment and prevention, and advocate for improved policies and services that make a difference. Already there are many evidence-based and promising practices programs, and these are reviewed. Once evidence-based interventions are identified, invariably a challenge is to scale them to reach the large numbers in need, to ensure that they reach the people least likely to receive care because of all sorts of barriers, and then to obtain the data to show that in fact positive outcomes have been achieved. Advances in technology (e.g., big data, machine learning, tracking behavior in real time) and the pervasiveness of social media in its many forms might help address these challenges, and that prospect too adds to the hope. The Handbook will have broad appeal. Professionals from multiple disciplines will be interested in this book because it is a unique source that accommodates the scope of interpersonal violence and abuse; gives conceptual perspectives; covers past, present, and future directions; and looks carefully at the strengths and limitations of what has been done to address violence. Moreover, violence connects with so many areas of research, including child and adolescent development, trauma, cultural and ethnic studies, gender studies, disability, health care, immigration, criminal justice, substance use – it is endless. Individuals beginning or pondering their careers can find a buffet of urgent areas of work where breakthroughs in science, services, and policy can save lives and improve well-being. The book is a remarkable resource and is without peer in its scope, accomplishments, and guide for our future in peacefully but effectively combatting violence and abuse across the lifespan. Yale University New Haven, CT, USA

Alan E. Kazdin

Preface

The leadership of the National Partnership to End Interpersonal Violence Across the Lifespan (NPEIV) envisioned this Handbook 4 years ago to further our goals of raising awareness, educating the community, as well as advancing efforts to reduce and eliminate violence and abuse across the lifespan. Our commitment was to involve an interdisciplinary, diverse group of people as a planning committee to be able to share their voices in this large and significant endeavor. The group comprised of researchers, practitioners, and advocates who deal with various forms of violence and abuse, including child and youth maltreatment, youth violence, intimate partner violence, sexual assault, abuse of older adults, adult survivors of child and adult abuse, and community violence. Experts from the fields of psychology, social work, public health, criminology, health care, theology, victim advocacy, and the law were involved in developing the content of this Handbook. Following numerous discussions, the Handbook parts were conceptualized, and this group, along with others, was invited to participate as section co-editors. In collaboration with the Editors-inChief assigned as liaisons to each part, they created content and solicited authors for the chapters. The initial expectation was 100 chapters. However, there were many suggestions for additional chapters and topics that enhanced the scope and comprehensiveness of the Handbook. The Handbook content was then coordinated by regular meetings and discussions of the six Editors-in-Chief and the 23 section co-editors during the past 3 years. Each Editor-in-Chief has more than 30 years of experience in interpersonal violence from a research and/or practice standpoint. This 5-volume Handbook has 202 chapters, and over 400 authors. The goal was to provide a reference work that can be the main resource for researchers, practitioners, and policymakers for the next decade or more. The emphasis was to address issues related to research, practice, policy, and advocacy within a trauma-informed, developmental, and intersectional framework. In addition, the chapters deal with controversial subjects as well as cutting-edge thinking and methods. By design, several important themes permeate various chapters. These include the developmental effects of adverse childhood experiences; the usefulness of a social ecological/biopsychosocial framework; the intersectionality of violence with gender, race, and poverty; and the primacy of trauma as both a cause of violence and a consequence of it. Many chapters also utilize a human rights framework, focusing on the overlap of the various forms of interpersonal violence. ix

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Preface

Similarly, some chapters emphasize a public health and social justice perspective, focusing on system responses. The Handbook is quite timely as well in that during the final stages of its production, the COVID-19 crisis hit and has had a significant impact, especially on child abuse and intimate partner violence. Thus, chapters dealing with interpersonal violence and abuse with respect to COVID-19, racism, and other tragedies have been included. There are also chapters dealing with racial trauma, community and school violence, as well as gun violence. For too long, violence has been accepted as an inevitable aspect of human nature. It is the most significant social problem facing society, and yet, the resources devoted to eliminating interpersonal violence and abuse are scant. It is our hope that the knowledge amassed in the Handbook will inform and inspire community leaders, advocates, lawmakers, and scientists globally to join us in our mission of eliminating interpersonal violence and abuse. September 2021

Robert Geffner Jacquelyn W. White L. Kevin Hamberger Alan Rosenbaum Viola Vaughan-Eden Victor I. Vieth Editors

Contents

Volume 1 Section I Interpersonal Violence and Abuse Across The Lifespan: Foundations and Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Robert Geffner, Jacquelyn W. White, L. Kevin Hamberger, Alan Rosenbaum, Viola Vaughan-Eden, and Victor I. Vieth 1

2

1

Fundamentals of Understanding Interpersonal Violence and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jacquelyn W. White and Robert Geffner

3

Integration of the Types of Interpersonal Violence Across the Lifespan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pearl S. Berman and Alexandra G. Hosack

27

3

A History of Interpersonal Violence: Raising Public Concern . . . Stéphanie Pache

59

4

Examining Interpersonal Violence from a Trauma-Informed and Human Rights Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . Kelly Graves and Yasmin Gay

81

5

Adverse Childhood Experiences: Past, Present, and Future Tamara A. Hamai and Vincent J. Felitti

....

97

6

Trauma-Informed Systems of Care . . . . . . . . . . . . . . . . . . . . . . . . Karen Rich and Megan R. Garza

121

7

Intersectionality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sujata Warrier

151

8

Historical and Contemporary Racial Trauma Among Black Americans: Black Wellness Matters . . . . . . . . . . . . . . . . . . . . . . . Gimel Rogers and Thema Bryant-Davis

165

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9

Defining Gun Violence Using a Biopsychosocial Framework: A Public Health Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sara Kohlbeck, Lauren Pederson, and Stephen Hargarten

10

Suicidality and Interpersonal Violence . . . . . . . . . . . . . . . . . . . . . Michael Levittan

11

A National Plan to End Interpersonal Violence Across the Lifespan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Victor I. Vieth and Pearl S. Berman

Section II Maltreatment and Victimization of Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ernestine Briggs, Theodore P. Cross, Amy Russell, Michelle Clayton, Javonda Williams, Stacie Schrieffer LeBlanc, Heather J. Risser, Viola Vaughan-Eden, and Victor I. Vieth 12

13

An Introduction to Child and Youth Maltreatment: Consequences and Considerations . . . . . . . . . . . . . . . . . . . . . . . . Viola Vaughan-Eden, Victor I Vieth, and Sandi Capuano Morrison Overview of Child Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . Katelyn Donisch and Ernestine C. Briggs

Section III Physical Abuse of Children and Adolescents . . . . . . . . Ernestine Briggs, Theodore P. Cross, Amy Russell, Michelle Clayton, Javonda Williams, Stacie Schrieffer LeBlanc, Heather J. Risser, Viola Vaughan-Eden, and Victor I. Vieth 14

15

16

17

201 219

249

275

277 291

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Parents Who Physically Abuse: Current Status and Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Christina M. Rodriguez and Doris F. Pu

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Corporal Punishment: From Ancient History to Global Progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Joan E. Durrant

343

Abusive Head Trauma: Understanding Head Injury Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Verena Wyvill Brown and Tamika J. Bryant

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Domestic Child Torture: Identifying Survivors and Seeking Justice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ann Ratnayake Macy

405

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Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Erin Wade, Stephen Messner, and Edward Richer

449

19

Abusive Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Marissa S. Cantu and Jamie S. Kondis

509

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20

Bruising in Suspected Child Maltreatment . . . . . . . . . . . . . . . . . . Robyn McLaughlin, Laura C. Stymiest, Michelle G. K. Ward, and Amy E. Ornstein

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21

Inflicted Thoracoabdominal Trauma . . . . . . . . . . . . . . . . . . . . . . Gloria S. Lee and Lori D. Frasier

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Munchausen Syndrome by Proxy . . . . . . . . . . . . . . . . . . . . . . . . . Randell Alexander and Deana Lashley

571

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Corporal Punishment: Finding Effective Interventions . . . . . . . . Robin D. Perrin and Cindy Miller-Perrin

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Child Physical Abuse: A Pathway to Comprehensive Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Heather J. Risser and Edessa David

25

Child and Youth Fatality Review . . . . . . . . . . . . . . . . . . . . . . . . . Robert N. Parrish and Theodore P. Cross

Section IV Neglect of Children and Adolescents . . . . . . . . . . . . . . Ernestine Briggs, Theodore P. Cross, Amy Russell, Michelle Clayton, Javonda Williams, Stacie Schrieffer LeBlanc, Heather J. Risser, Viola Vaughan-Eden, and Victor I. Vieth 26

The Etiology of Child Neglect and a Guide to Addressing the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Julia M. Kobulsky and Howard Dubowitz

609 635

657

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The Nature of Neglect and Its Consequences . . . . . . . . . . . . . . . . Julia M. Kobulsky and Howard Dubowitz

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Child Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sarah Passmore, Lauren Conway, and Michael Baxter

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Dental Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rosalyn E. Brownlee, Gail Benton, and Scott A. Benton

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Volume 2 Section V Sexual Abuse of Children and Adolescents . . . . . . . . . . Ernestine Briggs, Theodore P. Cross, Amy Russell, Michelle Clayton, Javonda Williams, Stacie Schrieffer LeBlanc, Heather J. Risser, Viola Vaughan-Eden, and Victor I. Vieth

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Sexual Abuse of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jon R. Conte and June Simon

741

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Child Sexual Abuse Disclosure and Forensic Practice . . . . . . . . . Jon R. Conte and June Simon

771

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33

34

35

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Contents

Succeeding with Nonoffending Caregivers of Sexually Abused Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Viola Vaughan-Eden, Stacie Schrieffer LeBlanc, and Yvette Dzumaga Recognizing and Responding to Developmentally Appropriate and Inappropriate Sexual Behaviors of Children: A Primer for Parents, Youth Serving Organizations, Schools, Child Protection Professionals, and Courts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Victor I. Vieth The People in Your Neighborhood: Working with Sexual and Gender Minority Youth as Victims of Sexual Violence . . . . . . . . . Amy Russell Adult Sex Offenders Against Children: Etiology, Typologies, Investigation, Treatment, Monitoring, and Recidivism . . . . . . . . Theodore P. Cross, Victor I. Vieth, Amy Russell, and Cory Jewell Jensen State-of-the-Art Measures: Contemporary Views on Risk Assessment of Sexually Abusive Youth . . . . . . . . . . . . . . . . . . . . . L. C. Miccio-Fonseca and Lucinda A. Lee Rasmussen

789

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831

857

885

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The Commercial Sexual Exploitation of Children . . . . . . . . . . . . Javonda Williams, Chris Lim, Valerie Trull, and Melody Higgins

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Abuse of Youth in Residential Settings/Institutions Roger A. Canaff

...........

931

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Technology-Facilitated Child Abuse . . . . . . . . . . . . . . . . . . . . . . . Robert J. Peters

953

40

Genital Examination Techniques . . . . . . . . . . . . . . . . . . . . . . . . . Nicole Ayson and Suzanne Starling

975

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Normal Examination Findings and Variants Nicole Ayson and Suzanne Starling

................

991

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Acute Sexual Assault Evaluation of the Prepubertal Child . . . . . 1005 Amber L. Shipman, Dawn Scaff, Cassandra Elverum, and Michelle Clayton

43

Abnormal Findings Diagnostic of Anogenital Trauma in Prepubertal Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1047 Michelle Clayton and Amber L. Shipman

44

Mimickers of Child Sexual Abuse . . . . . . . . . . . . . . . . . . . . . . . . . 1077 Jada Ingalls and Nancy S. Harper

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Section VI Emotional Abuse of Children and Adolescents . . . . . . 1113 Ernestine Briggs, Theodore P. Cross, Amy Russell, Michelle Clayton, Javonda Williams, Stacie Schrieffer LeBlanc, Heather J. Risser, Viola Vaughan-Eden, and Victor I. Vieth 45

Psychological Maltreatment of Children: Influence Across Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1115 Hilary B. Hodgdon and Ashley L. Landers

46

Psychological Maltreatment of Children and Youth: A Historical Perspective on the Right to Be Emotionally Safe . . . . . . . . . . . . . 1137 James Garbarino

47

Bullying and Cyberbullying Throughout Adolescence . . . . . . . . . 1153 Logan N. Riffle, Michelle L. Demaray, and Shengse R. Jeong

Section VII Family Violence and Teen Dating Violence . . . . . . . . 1181 Ernestine Briggs, Theodore P. Cross, Amy Russell, Michelle Clayton, Javonda Williams, Stacie Schrieffer LeBlanc, Heather J. Risser, Viola Vaughan-Eden, and Victor I. Vieth 48

Mother-Child Attachment in Violent Contexts: Effect of Complex Trauma and Maternal Trauma History . . . . . . . . . . . . 1183 Adella Nikitiades

49

Correlations Among Childhood Abuse and Family Violence, Prevention, Assessment, and Treatment from a Trauma-Focused Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1203 Marc V. Felizzi and Karen Rice

50

Implications of Maltreatment for Young Children . . . . . . . . . . . . 1225 Demara B. Bennett

51

Missing and Exploited Youth Alison Feigh

52

Youths’ Exposure to Violence in the Family . . . . . . . . . . . . . . . . . 1273 Gimel Rogers

53

Sibling Abuse of Other Children John Caffaro

54

Siblicide: The Psychology of Sibling Homicide . . . . . . . . . . . . . . . 1323 Inês Carvalho Relva and Roxanne Khan

55

Teen Dating Violence and Stalking . . . . . . . . . . . . . . . . . . . . . . . . 1343 Daniel C. Semenza and Jessica M. Grosholz

. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1249

. . . . . . . . . . . . . . . . . . . . . . . . . 1295

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Teen Dating Violence Policy: An Analysis of Teen Dating Violence Prevention Policy and Programming . . . . . . . . . . . . . . . 1365 Shannon Guillot-Wright, Yu Lu, Elizabeth D. Torres, Arlene Macdonald, and Jeff R. Temple

57

Child Survivors of Intimate Partner Homicide: Wraparound Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1381 Neil Websdale

Section VIII Cultural Issues Concerning Maltreatment of Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1401 Ernestine Briggs, Theodore P. Cross, Amy Russell, Michelle Clayton, Javonda Williams, Stacie Schrieffer LeBlanc, Heather J. Risser, Viola Vaughan-Eden, and Victor I. Vieth 58

Cultural Competence in the Field of Child Maltreatment . . . . . . 1403 Lisa Aronson Fontes

59

Recognizing and Responding to the Spiritual Impact of Child Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1425 Victor I. Vieth and Pete Singer

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The Experience of Children and Families Involved with the Child Welfare System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1441 Kathryn J. Murray, Jessica Dym Bartlett, and Maria C. Lent

61

Interpersonal Violence and Forced Displacement . . . . . . . . . . . . 1463 Wendy Wheaton, Alisa Miller, Ngozi Enelamah, and Theresa S. Betancourt

62

Child Maltreatment in Military Families: Risk and Protective Factors, and Family-Systems Interventions . . . . . . . . . . . . . . . . . 1487 Emily D. Wolodiger, Jonathan S. Goldner, Ashton M. Lofgreen, William R. Saltzman, Patricia E. Lester, and Niranjan S. Karnik

Volume 3 Section IX Consequences and Interventions for the Maltreatment of Children and Adolescents . . . . . . . . . . . . . . . . . . . 1513 Ernestine Briggs, Theodore P. Cross, Amy Russell, Michelle Clayton, Javonda Williams, Stacie Schrieffer LeBlanc, Heather J. Risser, Viola Vaughan-Eden, and Victor I. Vieth 63

Neurobiological Consequences of Child Maltreatment . . . . . . . . . 1515 Sherika N. Hill and Aysenil Belger

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The Intersection of Trauma and Substance Use in Adolescent Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1533 Angela M. Tunno, Heather T. Pane Seifert, Shayna Cheek, and David B. Goldston

65

Forensic Interviewing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1555 Kathleen Coulborn Faller

66

Linking Trauma-Informed Screening and Assessment Practices Across Child-Serving Systems . . . . . . . . . . . . . . . . . . . . 1579 Lisa Conradi, Cassandra Kisiel, and Linzy M. Pinkerton

67

Assessing Causes of Children’s Parent Rejection in Child Custody Cases: Differentiating Parental Alienation from Child Sexual Abuse, Psychological Maltreatment, and Adverse Parenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1607 Madelyn Simring Milchman

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Treatment Considerations for Youth Exposed to Interpersonal Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1629 Ilana S. Berman, Heather T. Pane Seifert, and Ernestine C. Briggs

69

Mental Health and Healthcare System Responses to Adolescent Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1661 Pete Singer

70

The Impact of Neighborhood-Based Interventions on Reducing Child Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1689 Amy Governale, Danielle Nesi, and James Garbarino

Section X Recognizing and Responding to Maltreatment of Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ernestine Briggs, Theodore P. Cross, Amy Russell, Michelle Clayton, Javonda Williams, Stacie Schrieffer LeBlanc, Heather J. Risser, Viola Vaughan-Eden, and Victor I. Vieth

1713

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Child Maltreatment: Mandated Reporting . . . . . . . . . . . . . . . . . . 1715 Betsy P. Goulet, Yu-Ling Chiu, and Theodore P. Cross

72

Child Welfare System: Structure, Functions, and Best Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1735 Theodore P. Cross and Heather J. Risser

73

The Child Welfare System: Problems, Controversies, and Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1769 Kelly M. Sullivan, Meghan Shanahan, Jeanne J. Preisler, and Nina Kane

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The Criminal Justice Response to Child and Youth Victimization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1797 Theodore P. Cross, Emelie Ernberg, and Wendy A. Walsh

75

The Law and Policy of Child Maltreatment . . . . . . . . . . . . . . . . . 1829 Frank E. Vandervort

76

Collecting Child Victimization Information from Youth and Parents: Ethical and Methodological Considerations . . . . . . . . . . 1851 Heather A. Turner

77

Responding to Child Abuse During a Pandemic . . . . . . . . . . . . . 1881 Victor I. Vieth, Robert J. Peters, Tyler Counsil, Rita Farrell, Rachel Johnson, Stacie Schrieffer LeBlanc, Alison Feigh, Jane Straub, and Pete Singer

Section XI Community Violence and Abuse: Victimization and Perpetration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Michael B. Greene, Robert L. Johnson, and Jacquelyn W. White

1903

78

Community Violence Overview: Guiding Principles, Critical Issues, and Prevention and Intervention Strategies . . . . . 1905 Michael B. Greene and Robert L. Johnson

79

Commonalities and Overlap Between Victims and Offenders . . . 1921 Chad Posick and Kalynn C. Gruenfelder

80

Microaggressions and Implicit Biases: Rooted in Structural Racism and Systemic Oppression . . . . . . . . . . . . . . . . . . . . . . . . . 1941 Kevin L. Nadal, Mawia Khogali, Patricia Châu Nguyễn, and Tanya Erazo

81

Violence in Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1965 Dewey G. Cornell and Shelby Stohlman

82

Empowerment Strategies and Youth Community Organizing . . . 1987 Sarah E. O. Schwartz, Kirsten M. Christensen, and Laura Austin

83

Hate Crimes: A Special Category of Victimization . . . . . . . . . . . . 2017 Matthew D. Fetzer and Frank S. Pezzella

84

Taking Stock of Gang Violence: An Overview of the Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2045 Matthew Valasik and Shannon E. Reid

85

Gang Violence: Examining Ecological, Cultural, Social Psychological, and Psychological Factors Across the Life Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2067 Timothy R. Lauger and Sou Lee

Contents

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86

The Juvenile Justice Response to Violence . . . . . . . . . . . . . . . . . . 2087 Jeffrey A. Butts and Jason Szkola

87

Girls in Juvenile Justice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2109 Susan McCarter, David McLeod, Vanessa Drew, and James Granberry

88

Sex and Labor Trafficking: Trauma-Informed Themes Toward a Social Justice Approach . . . . . . . . . . . . . . . . . . . . . . . . 2143 Dominique A. Malebranche, Elizabeth K. Hopper, and Elisabeth Corey

89

Sexual and Gender-Based Violence as Warfare . . . . . . . . . . . . . . 2171 Elena Cherepanov

Section XII Definitions, Prevalence, Terms, and Tactics for Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2197 Jennifer Langhinrichsen-Rohling, Glenna Tinney, Shelly M. Wagers, L. Kevin Hamberger, and Alan Rosenbaum 90

Introduction to the Intimate Partner Violence Section: History, Progress, and Lessons Learned . . . . . . . . . . . . . . . . . . . . . . . . . . . 2199 L. Kevin Hamberger, Jennifer Langhinrichsen-Rohling, Alan Rosenbaum, Glenna Tinney, and Shelly M. Wagers

91

Intimate Partner Violence: Terms, Forms, and Typologies . . . . . 2219 Richard E. Heyman, Danielle M. Mitnick, and Amy M. Smith Slep

92

Cyber Abuse in Romantic Relationships . . . . . . . . . . . . . . . . . . . 2249 Penny A. Leisring, Danielle M. Farrell, and Daniela M. Scotto

93

Advances in Understanding and Addressing the Link Between Pet Abuse and Intimate Partner Violence . . . . . . . . . . . . . . . . . . . 2279 Nancy Blaney, Mary Lou Randour, and Chelsea Blink

94

Intimate Partner Violence and Intimate Partner Stalking . . . . . . 2301 TK Logan and Jennifer Langhinrichsen-Rohling

Volume 4 Section XIII Theories and Key Factors for Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2325 Jennifer Langhinrichsen-Rohling, Glenna Tinney, Shelly M. Wagers, L. Kevin Hamberger, and Alan Rosenbaum 95

Feminist Perspectives of Intimate Partner Violence and Abuse (IPV/A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2327 Patricia Becker, Katherine Kafonek, and Jamie L. Manzer

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Masculinity and Violence Against Women from a Social-Ecological Perspective: Implications for Prevention . . . . . 2353 Dennis E. Reidy, Ashley S. D’Inverno, Katherine W. Bogen, Monica H. Swahn, and Genna M. Jacobs

97

Psychological Theories of Intimate Partner Violence . . . . . . . . . . 2375 Christopher I. Eckhardt and Andrea A. Massa

98

Substance Use and Intimate Partner Violence Perpetration . . . . 2399 Christopher I. Eckhardt, Dominic J. Parrott, and Andrea A. Massa

99

Intimate Partner Violence Across the Lifespan: Dyadic Theory and Risk and Protective Factors . . . . . . . . . . . . . . . . . . . . . . . . . . 2419 Deborah M. Capaldi, Sabina Low, Stacey S. Tiberio, and Joann Wu Shortt

100

Clarifying the Complex Roles of Power and Control in Advancing Theories of Intimate Partner Violence . . . . . . . . . . . . 2445 Shelly M. Wagers, L. Kevin Hamberger, and Christine S. Sellers

101

Relation Between Exposure to Parental Intimate Partner Violence During Childhood and Children’s Functioning . . . . . . . 2463 Patti A. Timmons Fritz and Emely Roy

102

Intergenerational Transmission of Intimate Partner Violence: Summary and Current Research on Processes of Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2485 Miriam K. Ehrensaft and Jennifer Langhinrichsen-Rohling

103

Neuropsychological and Psychophysiological Correlates of Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2511 D. Andrew Godfrey, Victoria E. Bennett, Alexandra L. Snead, and Julia Babcock

Section XIV Intersectionality with Respect to Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2537 Jennifer Langhinrichsen-Rohling, Glenna Tinney, Shelly M. Wagers, L. Kevin Hamberger, and Alan Rosenbaum 104

Inclusion and Exclusion: Intersectionality and Gender-Based Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2539 Sujata Warrier

105

Intersectionality and Intimate Partner Violence and Abuse: IPV and People with Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . 2553 Elizabeth P. Cramer, Sara-Beth Plummer, and Avina I. Ross

Contents

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106

Intimate Partner Abuse in Lesbian, Gay, Bisexual, Queer, Transgender and Two-Spirit (LGBQ/T and TS) Communities . . . . 2577 Erin C. Miller, Xavier Quinn, and Elizabeth Rosa Santiago

107

Intimate Partner Violence in Tribal Communities: Sovereignty, Self-Determination, and Framing . . . . . . . . . . . . . . . . . . . . . . . . . 2599 Caroline LaPorte

108

How Domestic Violence Impacts Immigrant Victims . . . . . . . . . . 2629 Grace Huang

109

Intimate Partner Violence Among Latina Survivors: Unique Considerations, Strategies, and Opportunities . . . . . . . . . . . . . . . 2655 Rebecca Rodriguez, Josephine Vasquez Serrata, Rosemarie Lillianne Macias, Rosie Hidalgo, Nancy Nava, and Olivia Garcia

110

Gender-Based Violence and Culturally Specific Advocacy in Asian and Pacific Islander Communities . . . . . . . . . . . . . . . . . 2675 Chic Dabby and Mieko Yoshihama

111

The Intersectionality of Intimate Partner Violence in the Black Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2705 Johnny Rice II, Carolyn M. West, Karma Cottman, and Gretta Gardner

Section XV Prevention of Intimate Partner Violence . . . . . . . . . . 2735 Jennifer Langhinrichsen-Rohling, Glenna Tinney, Shelly M. Wagers, L. Kevin Hamberger, and Alan Rosenbaum 112

Best Available Evidence for Preventing Intimate Partner Violence Across the Life Span . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2737 Phyllis Holditch Niolon, Lianne Fuino Estefan, Megan Kearns, and Linda L. Dahlberg

113

The Danger Assessment: An Instrument for the Prevention of Intimate Partner Homicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2761 Laurie M. Graham, Jill T. Messing, and Jacquelyn Campbell

114

Community-Informed Risk Assessment in Intimate Partner Violence and Abuse Cases: Origins, Development, and Deployment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2783 Neil Websdale

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Contents

Firearms, Domestic Violence, and Dating Violence: Abusers’ Use of Firearms Violence to Exert Coercive Control and Commit Intimate Partner Homicides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2815 Rob (Roberta) Valente and Rachel Graber

Section XVI Survivors, Economic, and Justice System Responses to Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2839 Jennifer Langhinrichsen-Rohling, Glenna Tinney, Shelly M. Wagers, L. Kevin Hamberger, and Alan Rosenbaum 116

Barriers to Leaving an Abusive Relationship . . . . . . . . . . . . . . . . 2841 Daniel G. Saunders

117

Economic Considerations of Intimate Partner Violence . . . . . . . . 2865 Jacqueline Strenio

118

Stigma and IPV Victimization . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2885 Allison Crowe and Christine E. Murray

119

System Response to Intimate Partner Violence: Coordinated Community Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2911 Melanie D. Hetzel-Riggin

120

Advocacy and Intimate Partner Violence . . . . . . . . . . . . . . . . . . . 2939 Patricia Branco, Casey Keene, Anne Menard, and Ivonne Ortiz

121

A Feminist Perspective on the Criminal Justice System Response to Domestic Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . 2973 Shannon B. Harper and Angela R. Gover

122

Supporting Family Justice Centers Through Research and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3003 Christine E. Murray and Catherine H. Johnson

123

Protection Orders: Shielding Intimate Partner Violence Victims from Harm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3021 Shannon B. Harper, Angela R. Gover, and Tara N. Richards

124

Intimate Partner Violence and Family Law: Focus on Separating and Divorcing Parents . . . . . . . . . . . . . . . . . . . . . . . . 3043 Claire S. Tomlinson, Lily J. Jiang, and Amy Holtzworth-Munroe

125

Intimate Partner Violence and Family Court . . . . . . . . . . . . . . . . 3071 Kelly M. Champion

126

Domestic Violence Fatality Review: The State of the Art . . . . . . . 3093 Neil Websdale

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xxiii

Section XVII Survivors: Health, Mental Health, and Disaster Impacts and Responses to Intimate Partner Violence . . . . . . . . . . 3117 Jennifer Langhinrichsen-Rohling, Glenna Tinney, Shelly M. Wagers, L. Kevin Hamberger, and Alan Rosenbaum 127

Addressing Intimate Partner Violence Within the Healthcare System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3119 Jennifer Langhinrichsen-Rohling, Mallory Schneider, Candice Selwyn, Emma Lathan, Lameace Sayegh, and L. Kevin Hamberger

128

Intimate Partner Violence and Sleep: An Overview of Sleep Disturbances and Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . 3149 Priya E. Maharaj, Nicola Barclay, Christine Descartes, and Hazel Da Breo

129

The US Mental Health Care System’s Response to Intimate Partner Violence: A Call to Action . . . . . . . . . . . . . . . . . . . . . . . . 3175 Jennifer Langhinrichsen-Rohling, Candice Selwyn, Emma Lathan, and Mallory Schneider

130

Mental Health Treatment in the Context of Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3201 Carole Warshaw and Gabriela A. Zapata-Alma

131

Treatment of Post-traumatic Stress Disorder in Survivors of Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3223 Dawn M. Johnson, Caron Zlotnick, and Alejandra Gonzalez

132

Male Victims of Female-Perpetrated Intimate Partner Violence: History, Controversy, and the Current State of Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3247 Denise A. Hines and Emily M. Douglas

133

Feminist Perspectives on Disaster, Pandemics, and Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3267 Margaret B. Drew

Volume 5 Section XVIII Intimate Partner Violence: Special Populations . . . 3287 Jennifer Langhinrichsen-Rohling, Glenna Tinney, Shelly M. Wagers, L. Kevin Hamberger, and Alan Rosenbaum . . . 3289

134

Intimate Partner Violence: Military Personnel and Veterans April Gerlock and Glenna Tinney

135

Intimate Partner Violence in College Settings . . . . . . . . . . . . . . . 3317 Lindsey M. Rodriguez, Victoria Beltran, and Tiffany Chenneville

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Human Trafficking and Intimate Partner Violence . . . . . . . . . . . 3339 Joan A. Reid, Tara N. Richards, and Teresa C. Kulig

137

Poly-victimization: The Co-occurrence of Intimate Partner Violence with Other Forms of Aggression . . . . . . . . . . . . . . . . . . 3361 Lauren Bradel-Warlick and Alan Rosenbaum

Section XIX Perpetrators and Interventions for Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jennifer Langhinrichsen-Rohling, Glenna Tinney, Shelly M. Wagers, L. Kevin Hamberger, and Alan Rosenbaum

3385

138

Relationship Violence Perpetrator Intervention Programs: History and Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3387 Christopher M. Murphy, Alan Rosenbaum, and L. Kevin Hamberger

139

The Efficacy of Psychosocial Interventions for Partner Violent Individuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3417 Christopher M. Murphy and Tara N. Richards

140

Alternative to Violence, a Violence-Focused Psychotherapy for Men Using Violence Against Their Female Partner . . . . . . . . 3445 Ingunn Rangul Askeland, Bente Lømo, Marius Råkil, and Per Isdal

141

Couples Counseling to End Intimate Partner Violence Sandra M. Stith and Chelsea M. Spencer

142

Female Perpetrators of Intimate Partner Violence . . . . . . . . . . . . 3491 Lynn Dowd and Lesley Lambo

. . . . . . . . 3471

Section XX Adult Sexual Harassment and Assault: Victimization and Perpetration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3517 Sarah Cook, Tracy N. Hipp, Thema Bryant-Davis, Rebecca Wilson, Marie Skov, Kevin Swartout, and Jacquelyn W. White 143

Rape Persists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3519 Sarah L. Cook, Tracy N. Hipp, and Rebecca A. Wilson

144

Sexual Assault Perpetration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3533 Karol E. Dean and Kevin Swartout

145

A Conceptual Overview of Drugging: It’s Not What You Think . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3557 Suzanne C. Swan, Jessica B. Pomerantz, Bonnie S. Fisher, and Nicole V. Lasky

146

Nature and Scope of Technology-Facilitated or Related Sexual Violence: Focus on Pornography . . . . . . . . . . . . . . . . . . . . 3579 Jennifer Kusz and Nicole Wilkes

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147

Underground Anti-woman and Incel Movements and Their Connections to Sexual Assault . . . . . . . . . . . . . . . . . . . . . . 3601 Sara M. Abdulla

148

The Nature and Scope of Sexual Assault Victimization of Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3627 Leah E. Daigle and Andia Azimi

149

Health and Mental Health Consequences from Sexual Trauma Victimizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3649 Melanie J. Bliss

150

Disclosing Sexual Assault: Understanding the Culture of Nondisclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3673 Veronica R. Barrios and Jonathan Caspi

151

False Reporting of Sexual Victimization: Prevalence, Definitions, and Public Perceptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3691 Lindsay Orchowski, Katherine W. Bogen, and Alan Berkowitz

152

Sexual Harassment Communication Across the Context and the Lifespan: An Interdisciplinary Perspective . . . . . . . . . . . . . . . . . . 3715 Jennifer A. Scarduzio, Jessica L. Ford, and Sonia Ivancic

153

The Cultural Context of Sexual Assault and Its Consequences Among Ethnic Minority Women . . . . . . . . . . . . . . . . . . . . . . . . . . 3741 Robyn L. Gobin and Jennifer M. Gómez

154

Unsafe Sanctuary: Immigrants of Color Victims of Sexual Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3765 Lillian Comas-Díaz

155

Sexual Abuse Among Individuals with Disabilities Lauren A. Stutts

156

Sexual Violence among Sexual and Gender Minorities . . . . . . . . 3813 Melissa S. Beyer, Amanda C. Toumayan, and Tracy N. Hipp

157

Identifying, Attending, and Protecting US Sex Trafficked Adults and Minors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3839 Paola M. Contreras

158

Men Stopping Violence’s Definition of Male Sexual Violence Against Women: Implications for Prevention and Intervention Ulester Douglas, Lee Giordano, and Greg Loughlin

159

. . . . . . . . . . . 3783

. . . 3861

Reforming Comprehensive Sexuality Education to Prevent Sexual Assault . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3885 Lisa P. Armistead, Nicholas Tarantino, Charlene Collibee, Sarah L. Cook, and Martha Ishiekwene

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New Environmental Approaches to Preventing Sexual Assault: Building on a History of Individual-Level Interventions . . . . . . . 3913 Bruce G. Taylor and Elizabeth A. Mumford

161

Sexual Harassment Training: Why It (Currently) Doesn’t Work and What Can Be Done . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3941 Alexandra I. Zelin and Vicki J. Magley

162

Interventions in the Aftermath of Sexual Violence: Justice, Advocacy, and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3963 Melissa Ashton, Tracy N. Hipp, Jessica E. Mandell, and Theresa Prichard

163

Treatment Interventions for Perpetrators of Sexual Violence Raina V. Lamade and Adedoyin Okanlawon

164

Military Sexual Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4015 Rae Anne Frey-Ho Fung, Sadie E. Larsen, and Robyn L. Gobin

165

Sexual Violence and Religious Institutions: With a Special Focus on the Catholic Church . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4035 Dylan Abrams, Alex Bonagura, and Cynthia Calkins

166

Sexual Violence in the Context of Higher Education: The Current State of Research and Policy . . . . . . . . . . . . . . . . . . . . . . 4061 Alexandra L. Bellis

167

Bars as a Drinking Context for Sexual Aggression . . . . . . . . . . . 4083 Kathleen A. Parks, R. Lorraine Collins, Kathryn Graham, Sharon Bernards, and Samantha Wells

168

Sexual Violence in Athletic Organizations Kristy L. McCray and Elizabeth A. Taylor

169

Wartime Sexual Violence: A Historical Review of the Law, Theory, and Prevention of Sexual Violence in Conflict . . . . . . . . 4121 Rebecca A. Wilson and Sarah L. Cook

170

Improving the Police Response to Rape Victims: Persistent Challenges and New Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . 4135 Karen Rich

171

Title IX and Restorative Justice as Informal Resolution for Sexual Misconduct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4153 Elise C. Lopez and Mary P. Koss

. . . 3985

. . . . . . . . . . . . . . . . . . 4107

Contents

xxvii

Volume 6 Section XXI Adult Survivors of Childhood Abuse and Victimization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Christine A. Courtois, Sylvia A Marotta-Walters, Carlos A. Cuevas, and Robert Geffner

4175

172

Progress in Understanding Victim-Survivors of Interpersonal Violence: Introduction to the Section . . . . . . . . . . . . . . . . . . . . . . 4177 Christine A. Courtois, Sylvia A. Marotta-Walters, and Carlos A. Cuevas

173

The Contemporary Study of Adult Survivors of Interpersonal Violence and the Development of Mental Health Treatment . . . . 4183 Christine A. Courtois and Sylvia A. Marotta-Walters

174

Lifespan and Intergenerational Promotive and Protective Factors Against the Transmission of Interpersonal Violence in Diverse Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4209 Angela J. Narayan, Jillian S. Merrick, Laura M. River, and Alicia F. Lieberman

175

Adult Sequelae of Childhood Interpersonal Violence . . . . . . . . . . 4231 Reese Minshew

176

Impact of Childhood Maltreatment and Polyvictimization on Adult Revictimization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4255 Melanie P. Duckworth, Tony Iezzi, Megan Radenhausen, and Kristel-Ann Galarce

177

Impact of Interpersonal, Family, Cultural, and Institutional Betrayal on Adult Survivors of Abuse . . . . . . . . . . . . . . . . . . . . . 4275 Alexis A. Adams-Clark, Jennifer M. Gómez, Robyn L. Gobin, Laura K. Noll, and Brianna C. Delker

178

The Tapestry of Identity: Understanding Intersectionality Within Victimization Experiences, Consequences, and Treatment of Adult Survivors of Abuse . . . . . . . . . . . . . . . . . . . . 4303 Sarah Lockwood, Kelly Goggin, and Carlos A. Cuevas

179

Clinical Perspectives About Male Sexual Victimization: The Cultural and Historical Context of Gender . . . . . . . . . . . . . . . . . 4317 Jim Struve and Joanna Colrain

180

Assessment and Clinical Decision-Making with Adult Survivors of Interpersonal Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4351 Rachel E. Liebman, Brian Van Buren, and Damion Grasso

181

Dissociation, Dissociative Disorder, and Their Treatment . . . . . . 4383 Constance Dalenberg, Brandi Naish, and Ana Abu-Rus

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The Health Effects of Childhood Abuse and Adversity: Mechanisms, Consequences, and Trauma-Informed Care . . . . . . 4409 Kathleen Kendall-Tackett

183

Attachment Styles and Vicarious Trauma Ginny Sprang

. . . . . . . . . . . . . . . . . . 4425

Section XXII Older Adult and Elder Abuse: Victimization and Perpetration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4443 Mary Beth Quaranta Morrissey, Thomas Caprio, L. Kevin Hamberger, and Alan Rosenbaum 184

Introduction: Abuse in Later Life . . . . . . . . . . . . . . . . . . . . . . . . . 4445 Mary Beth Quaranta Morrissey and Thomas Caprio

185

Intimate Partner Violence in Later Life . . . . . . . . . . . . . . . . . . . . 4457 Cailin Crockett and Bonnie Brandl

186

Sexual Victimization of the Elderly: An Examination of the Emergent Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4479 Jessie L. Krienert and Jeffrey A. Walsh

187

Recognizing the Trauma Experienced by Community-Dwelling Older Victims of Financial Abuse Perpetrated by Trusted Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4499 Shelly L. Jackson

188

Neglect and Self-Neglect of Older Adults . . . . . . . . . . . . . . . . . . . 4519 Carmel Dyer, Michael Brad Cannell, and Jason Burnett

189

Polyvictimization and Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . 4545 Pamela B. Teaster and Holly Ramsey-Klawsnik

190

Perpetrators of Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4561 Pamela B. Teaster and Karen A. Roberto

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Systems Responses to Older Adult and Elder Abuse . . . . . . . . . . 4581 Joy Swanson Ernst

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Elder Abuse in Asia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4603 Elsie Yan and Boye Fang

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Caregiving and Elder Abuse: A Complex Relationship . . . . . . . . 4633 Georgia J. Anetzberger

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Intersectionality of Elder Abuse and Mental Health Issues: Needs and Interventions for Victims . . . . . . . . . . . . . . . . . . . . . . . 4659 Jo Anne Sirey, Maria Minor, and Jacquelin Berman

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Mothers’ Perspectives on Abuse by Adult Children . . . . . . . . . . . 4673 Judith R. Smith

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Intersectionality of Race, Ethnicity, and Culture in Neglect, Abuse, and Violence Against Older Persons: Human Rights, Global Health, and Systems Approaches in Pandemics . . . . . . . . 4699 Mary Beth Quaranta Morrissey, Patricia Brownell, and Thomas Caprio

Section XXIII Future Directions in Interpersonal Violence and Abuse Across the Lifespan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4721 Robert Geffner, Jacquelyn W. White, L. Kevin Hamberger, Alan Rosenbaum, Viola Vaughan-Eden, and Victor I. Vieth 197

Future Directions in System Responses to Interpersonal Violence and Abuse: Community Perspectives . . . . . . . . . . . . . . . . . . . . . . 4723 Tracy Sbrocco, Khalilah M. Mccants, Megan W. Blankenship, Michele M. Carter, and Patrick H. Deleon

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Future Directions in Interpersonal Violence and Abuse Interventions Across the Lifespan . . . . . . . . . . . . . . . . . . . . . . . . . 4753 Michael Levittan, Nada Yorke, Mary Beth Quaranta Morrissey, Thomas Caprio, and Patricia Brownell

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Future Directions in Advocacy in Response to Interpersonal Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4791 Alicia Sanchez Gill and Nkiru Nnawulezi

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Trauma and Violence Across the Lifespan: Public Policy Advances, Challenges, and Future Directions . . . . . . . . . . . . . . . 4813 Diane Elmore Borbon and Elizabeth M. Tant

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Future Directions in Interpersonal Violence Prevention Across the Lifespan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4835 Aliya R. Webermann and Christopher M. Murphy

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The Evolution of Interpersonal Violence Research and Prevention Across the Lifespan in the United States: The Past, Present, and Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4859 Phyllis Holditch Niolon, Sarah Treves-Kagan, Linda L. Dahlberg, and James A. Mercy

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4887

About the Editors

Robert Geffner Institute on Violence Abuse and Alliant International University San Diego, CA, USA Robert Geffner, PhD, ABPP, ABN, is President and Founder of a nonprofit international resource and training center, the Family Violence and Sexual Assault Institute (FVSAI) dba Institute on Violence, Abuse & Trauma (IVAT). Celebrating its 35th anniversary, IVAT started in Texas and now has been in California for more than 20 years. IVAT has seven departments, including direct professional and clinical services, training, international summits, research, publications, dissemination, and accredited to provide continuing education. Dr. Geffner was Professor of Psychology at the University of Texas-Tyler for 17 years, and now Distinguished Research Professor of Psychology at Alliant International University in San Diego for more than 20 years. He is Editor-in-Chief of four professional peer-reviewed, international disseminated journals: Journal of Child Sexual Abuse; Journal of Aggression, Maltreatment & Trauma; Journal of Family Trauma, Child Custody, & Child development; and Journal of Child & Adolescent Trauma. He has a Diplomate in Clinical Neuropsychology from the American Board of Professional Neuropsychology and is Board Certified in Couple and Family Psychology from the American Board of Professional Psychology. He is Fellow in several divisions of the American Psychological Association as well as in other professional organizations. Dr. Geffner has been a licensed clinician for more than 40 years. He is currently a Psychologist in CA and TX, xxxi

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About the Editors

and as a Marriage and Family Therapist in CA. He has built several private practice mental health clinics, three of which are still in operation. He directed a full-service private practice mental health clinic in East Texas for more than 15 years prior to relocating to California 20 years ago. Dr. Geffner has lectured and trained extensively, nationally and internationally, for more than 35 years on a variety of subjects, including child abuse, domestic violence, trauma, forensic psychology, child custody, expert witness, human aggression, sexual assault and abuse, long-term effects of adverse childhood experiences, the effects of abuse and victimization on the brain, neurobiology of trauma and aggression, interpersonal violence and abuse in criminal, civil, and family court cases, issues of victimization and offending for civil and criminal cases, and diagnostic assessment. He has presented over 625 keynote addresses, plenaries, workshops, and seminars at international, national, regional, and state conferences. He has written, edited, co-authored, or co-edited more than 100 professional books, chapters, journal articles, and technical reports. Dr. Geffner is Founding Member and Past President of the American Psychological Association Division of Trauma Psychology, Founding Co-Chair and Past President of the National Partnership to End Interpersonal Violence Across the Lifespan (NPEIV), and Past President of the American Academy of Couple and Family Psychology. He has been a researcher, trainer, practitioner, and consultant for over 40 years. Jacquelyn W. White Department of Psychology College of Arts and Sciences University of North Carolina at Greensboro Greensboro, NC, USA Jacquelyn W. White, PhD, Emerita Professor of Psychology, is former Director of Women’s and Gender Studies and former Associate Dean for Research in the College of Arts and Sciences at the University of North Carolina at Greensboro. She is the Co-editor of Violence Against Women and Children and the Handbook on the Psychology of Women. She has conducted research on gender issues, sexual victimization, and intimate partner violence for over 40 years, and led one of the first

About the Editors

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longitudinal studies of sexual and physical dating violence among adolescents and college students. She recently led the US Department of Justice’s Office of Violence Against Women’s research and evaluation strategic planning project, identifying a series of next steps to advance victim safety and perpetrator accountability built around community capacity and coordinated community responses. She is Co-founder and Past President of the National Partnership to End Interpersonal Violence, as well as one of the co-organizers of the AdministratorResearcher Campus Climate Consortium, a national group working to ensure that campus climate surveys of sexual misconduct are rooted in empirically based research. She is Past Editor of Psychology of Women Quarterly, Past President of the Southeastern Psychological Association, and Past President of the Society for the Psychology of Women. She received the Society for the Psychology of Women’s 2008 Carolyn Wood Sherif Award and the 2011 Sue Rosenberg Zalk Award for Service. In 2010, she received the American Psychological Association Committee of Women’s Leadership Award. In 2018 she received the IVAT Volunteer of the Year Award. Dr. White has also been involved in a number of advocacy activities based on her research, including discussing priorities of VAWA-funded grant programs for the Committee on Law and Justice, National Academies of Science, Washington, DC; providing a Capitol Hill congressional briefing on understanding and addressing dating abuse among teens and young adults, sponsored by National Domestic Violence Hotline, Love is Respect, and the Mary Kay Foundation, Capitol Hill; addressing the cycle of sexual assault at the Prevention, Identification, Reporting and Response, Risk Assessment Network and Exchange Conference on Risks for Higher Education in New York City; and presenting a Congressional Lunch Seminar entitled Focus on Campus Sexual Assault: What We Know, How We Know It, and What to Do About It sponsored by the Society for the Psychological Study of Social Issues.

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About the Editors

L. Kevin Hamberger Department of Family and Community Medicine Medical College of Wisconsin Milwaukee, WI, USA L. Kevin Hamberger, PhD, is Professor of Family and Community Medicine, Medical College of Wisconsin. Since 1982, his research, scholarship, clinical work, and community work have been in the area of intimate partner violence. For 27 years, Dr. Hamberger conducted a program of treatment and research for domestically violent men. In this arena, Dr. Hamberger’s research focused on characteristics and treatment outcomes with domestically violent offenders, including study of treatment effectiveness, predicting premature treatment termination, and recidivism following treatment completion. More recently, he has studied different gender-related contexts and motivations for the use of violence against intimate partners. This research focused on identification of motivations for using IPV among men and women who used force against their intimate partners, and development of gender-specific interventions for males and females arrested for IPV. A third area of research Dr. Hamberger has engaged in is IPV as a healthcare issue. In particular, he has studied prevalence of IPV in family medicine settings and was PI on the CDC-funded program Healthcare can change from within – a project that demonstrated that when the clinic system changes to support IPV screening and brief intervention, more patients are screened and make fewer doctor visits, but view the health clinic as a resource for help with IPV. He is also presently collaborating with colleagues to develop and implement trauma informed care principles into primary care medical practice settings. He is on the editorial boards of four peerreviewed journals dedicated to the study of interpersonal violence. Dr. Hamberger has also served on several grant review committees for the NIH, CDC, and NIJ. He has published over 120 articles and chapters and 6 books, including Treating Men Who Batter: Theory, Practice and Programs (with P. Lynn Caesar), Domestic Partner Abuse (with Claire Renzetti), and Domestic Violence Screening and Intervention in Medical and Mental Healthcare Settings (with Mary Beth Phelan). Dr. Hamberger also served on the Board of Directors of a women’s shelter and advocacy program in Southeastern

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Wisconsin for more than 10 years and on the Wisconsin Governor’s Council on Domestic Abuse for 25 years. He was a Founding Member and leader of the Wisconsin Batterers Treatment Provider Association and a Member of the Board of Directors of the National Partnership to End Interpersonal Violence, where he co-chaired the Translation and Dissemination Committee. In 2011, Dr. Hamberger was recognized by the Institute on Violence, Abuse and Trauma (IVAT) with the Linda Saltzman Intimate Partner Violence Researcher Award, and in 2019, he was recognized by the National Partnership to End Interpersonal Violence with the Heritage Award, which recognizes lifetime achievement in work to end and prevent interpersonal violence. Alan Rosenbaum Department of Psychology Northern Illinois University DeKalb, IL, USA Alan Rosenbaum, PhD, is Professor Emeritus of Clinical Psychology at Northern Illinois University. During his 40 years career, he published more than 100 articles, books, and book chapters. He was one of the first psychologists to study and publish research-based articles on intimate partner violence, including the first empirical study of batterers using data collected from the batterers themselves. He also published the first studies on the effects of battering on witnessing children, as well as the first studies examining the relationship between head injury, neuropsychological functioning, and intimate partner violence. Dr. Rosenbaum has given hundreds of keynote addresses, presentations, lectures, and workshops, nationally and internationally. He developed and operated, for 15 years, the Men’s Educational Workshop, which was the largest university-based batterer intervention/anger management program in the United States. He has been awarded more than a million dollars in research grants from the National Institutes of Mental Health (NIMH). Dr. Rosenbaum received the Paul J. Barreira Excellence in Teaching Award from the University of Massachusetts Medical School, Department of Psychiatry, and the Linda Saltzman Memorial Intimate Partner Violence Researcher Award from the Institute of Violence, Abuse and Trauma

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About the Editors

(IVAT). His non-professional passions are painting and Destination Imagination, the largest global nonprofit educational program for children dedicated to inspiring the next generation of innovators, leaders, and creative problem solvers in the world. Viola Vaughan-Eden Ethelyn R. Strong School of Social Work Norfolk State University Norfolk, VA, USA Viola Vaughan-Eden, PhD, MSW, MJ, is Associate Professor and PhD Program Director with The Ethelyn R. Strong School of Social Work at Norfolk State University. She is also Co-founder of The UP Institute, a think tank for upstream child abuse solutions. As a forensic and licensed clinical social worker, Dr. Vaughan-Eden serves as a consultant and expert witness in child maltreatment cases – principally sexual abuse. She has provided mental health services to trauma victims and their families in Southeastern Virginia for more than 30 years. She has also evaluated and consulted on more than 3000 cases of child maltreatment and provided expert testimony more than 600 times, having served as an expert witness throughout Virginia as well as several other states and three branches of US Military Court. Dr. Vaughan-Eden is President Emerita of the National Partnership to End Interpersonal Violence (NPEIV), President Emerita of the American Professional Society on the Abuse of Children (APSAC), and Past President of the National Organization of Forensic Social Work (NOFSW). She lectures nationally and internationally on child and family welfare to multidisciplinary groups of professionals. She has been a speaker throughout the United States and abroad including Ireland, Japan, Netherlands, Russia, Spain, Turkey, and United Arab Emirates. She has trained mental health professionals, psychology interns, medical residents, physicians, social workers, guardians ad litem, judges, and law enforcement to enhance their awareness of and improve their response to child maltreatment. Additionally, Dr. Vaughan-Eden is the former Editorin-Chief of the Journal for Forensic Social Work, former Editorial Advisor for the Journal of Social Work

About the Editors

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Education, and on the editorial board of numerous other peer-refereed journals including the Journal of Child Sexual Abuse. She is the author of several child abuse– related articles and book chapters. Dr. Vaughan-Eden was a panelist on two Congressional Briefings – Spare the Rod, Protect the Child: A Reconsideration of Corporal Punishment of Children in Homes and Schools (November 2015) and Protecting Child Safety in Family Court (September 2016). She is the recipient of several awards and honors including as a 2019 Council of Social Work Education Leadership Scholar, 2015 Family and Children’s Trust Fund of Virginia Child Welfare Award, 2014 Champions for Children Community Service Award, 2012 National Association of Social Workers Virginia Chapter Lifetime Achievement Award, and 2011 National Children’s Advocacy Center’s Outstanding Service Award in Mental Health. Dr. Vaughan-Eden has a PhD in Social Work from Virginia Commonwealth University, a Master of Social Work from Norfolk State University, and a Master of Jurisprudence in Children’s Law and Policy from Loyola University Chicago School of Law. See www. violavaughaneden.com Victor I. Vieth Education and Research, Zero Abuse Project St. Paul, MN, USA Victor Vieth, JD, MA, is the Director of Education and Research for the Zero Abuse Project. He is also the Chair of the Academy on Violence and Abuse and Founder of the National Child Protection Training Center. He previously served as Executive Director of the National Center for the Prosecution of Child Abuse. Mr. Vieth has trained thousands of child protection professionals from all 50 states, 2 US territories, and 17 countries on numerous topics pertaining to child abuse investigation, prosecution, and prevention. He has been instrumental in implementing 22 state and international forensic interview training programs. He has been a leader in developing and implementing undergraduate and graduate programs to dramatically improve the training of future child protection professionals. These reforms have been implemented in more

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About the Editors

than 80 universities, medical schools, law schools, and seminaries in 28 states. Mr. Vieth serves on the Board of Directors of GRACE (Godly Response to Abuse in the Christian Environment) and Sacred Spaces, which works to empower Jewish communities to improve the response of faith communities to issues of child maltreatment. He also serves on the Board of the American Professional Society on the Abuse of Children. Mr. Vieth developed a program to train chaplains to assist Children’s Advocacy Centers and MDTs to address the spiritual impact of child abuse. He has helped implement chaplaincy programs at three accredited CACs. Mr. Vieth gained national recognition for his work addressing child abuse in small communities as a prosecutor in rural Minnesota. He is the recipient of numerous awards including the Pro Humanitate Award for Child Advocacy from the North American Child Resource Center for Child Welfare and the Heritage Service Award from the National Partnership to End Interpersonal Violence. Mr. Vieth has published numerous peer-reviewed journal articles, book chapters, books, and other writings pertaining to child abuse and neglect. He has consulted with public policy makers throughout the country and has testified before the United States Senate Judiciary Committee on reforming child protection education. He holds degrees from Winona State University, Hamline University School of Law, and Wartburg Theological Seminary.

About the Section Editors

Ernestine Briggs-King Department of Psychiatry and Behavioral Sciences Duke University Medical Center Durham, NC, USA Ernestine Briggs-King, PhD, is the Director of Research at the Center for Child and Family Health (CCFH), Director of the Data and Evaluation Program at the UCLA-Duke University National Center for Child Traumatic Stress, and Associate Professor in the Department of Psychiatry and Behavioral Sciences at Duke University School of Medicine. Her clinical and research interests include minority mental health, resiliency, reducing disparities, chronic adversity, child maltreatment and traumatic stress. Section Co-editor – Maltreatment and Victimization of Children and Adolescents Thema Bryant-Davis Pepperdine University Los Angeles, CA, USA Thema Bryant-Davis, PhD, is a licensed psychologist, Professor of Psychology at Pepperdine University, and Director of the Culture and Trauma Research Lab. She is a past psychology representative to the United Nations and Past President of the Society for the Psychology of Women. Dr. Bryant-Davis has published and presented on interpersonal trauma, including racial trauma. She is the author of the book Thriving in the Wake of Trauma: A Multicultural Guide. IVAT honored her for trauma media and trauma psychology mentorship. Section Coeditor – Adult Sexual Harassment and Assault

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About the Section Editors

Thomas Caprio Finger Lakes Geriatric Education Center University of Rochester Medical Center Rochester, NY, USA Thomas Caprio, MD, MPH, MS, is Professor of Medicine, Psychiatry, Dentistry, Nursing, and Public Health at the University of Rochester and serves as Chief Medical Officer for Home Care and Hospice. Dr. Caprio oversees the Finger Lakes Geriatric Education Center, which provides education related to geriatrics, palliative care, and elder abuse. He is Past President of the State Society on Aging of New York, as well as Past President of the National Association for Geriatric Education Centers and the National Association for Geriatric Education. Section Co-editor – Older Adult and Elder Abuse Michelle Clayton Eastern Virginia Medical School/Children’s Hospital of The King’s Daughters Norfolk, VA, USA Michelle Clayton, MD, MPH, FAAP, is a board-certified specialist in Child Abuse Pediatrics and an Associate Professor of Pediatrics at Eastern Virginia Medical School. She teaches medical, investigative, and judicial audiences about child abuse and neglect. Dr. Clayton has performed thousands of consultations and frequently provides expert testimony. She conducts research in the field and has received regional, statewide, and national awards recognizing her work on behalf of abused and neglected children. Section Coeditor – Maltreatment and Victimization of Children and Adolescents Sarah L. Cook Department of Psychology Georgia State University Atlanta, GA, USA Sarah L. Cook, PhD, is Professor, Department of Psychology and Interim Dean, Honors College at Georgia State University. She is a nationally recognized expert on violence against women. Her research explores how science conceptualizes and measures the problem,

About the Section Editors

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ethical issues in researching it, how to prevent it, and how it intersects with other problems such as HIV/AIDS in South Africa. Dr. Cook has been funded by the National Institute of Justice, Centers for Disease Control and Prevention, and National Institutes of Health. Section Co-editor – Adult Sexual Harassment and Assault Christine A. Courtois Trauma Psychology and Treatment Bethany Beach, DE, USA Christine A. Courtois, PhD, ABPP, is a board-certified counseling psychologist who is semi-retired as a consultant/trainer on trauma psychology and treatment after 35 years in clinical practice. She has received numerous professional awards and authored books on trauma responses and treatment. Dr. Courtois was Chair of the Clinical Practice Guideline for the Treatment of PTSD in Adults (APA, 2017). She is Past President of APA Division 56 (Trauma Psychology) and served on the Board of the International Society for Traumatic Stress Studies (ISTSS). Section Co-editor – Adult Survivors of Abuse Theodore P. Cross University of Illinois at Urbana-Champaign Champaign, IL, USA Theodore P. Cross, PhD, is Senior Research Professor at the Children and Family Research Center in the School of Social Work at the University of Illinois at UrbanaChampaign. He has studied the criminal justice and child protection response to child victimization for more than 30 years. His special topics of interest include Children’s Advocacy Centers, prosecution of child abuse, biological evidence in sexual assault cases, well-being in child welfare, and polygraph testing in child sexual abuse cases. Section Co-editor – Maltreatment and Victimization of Children and Adolescents

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About the Section Editors

Carlos A. Cuevas Violence and Justice Research Laboratory School of Criminology and Criminal Justice Northeastern University Boston, MA, USA Carlos A. Cuevas, PhD, is Professor and Co-director of the Violence and Justice Research Laboratory at Northeastern University in the School of Criminology and Criminal Justice. Dr. Cuevas’s research is in the area of victimization and trauma, sexual violence, and family violence. He focuses on victimization among Latinos, examining the scope and impact of bias crime against Latinos. As a clinical psychologist, he also provides services to trauma survivors and victims of violence. Section Co-editor – Adult Survivors of Abuse Michael B. Greene Rutgers University: School of Criminal Justice Newark, NJ, USA Michael B. Greene, PhD, received his doctorate from Columbia University in developmental psychology in 1980. He subsequently founded two major centers for the prevention of violence, including the Violence Institute of New Jersey. He has published and lectured widely on the nature, dynamics, and prevention of youth and school violence. His work is infused with a social justice and human rights perspective, and the role that community youth organizing plays in the prevention of violence as well as in fostering positive youth development. Section Co-editor – Community Violence and Abuse Tracy N. Hipp Department of Psychology University of Memphis Memphis, TN, USA Tracy N. Hipp, PhD, is a community psychologist and researcher focusing on the prevention of sexual violence. Prior to joining the University of Memphis, she worked with the CDC’s Division of Violence Prevention. Dr. Hipp’s work encompasses four key areas: (1) risk and protective factors for sexual violence victimization and perpetration; (2) resilience among sexual

About the Section Editors

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and gender minorities (LGBTQ+), including survivors of sexual violence; (3) community and policy-level influences on violence; and (4) social justice and health equity for marginalized populations. Section Co-editor – Adult Sexual Harassment and Assault Robert L. Johnson Rutgers Medical School and The Robert Wood Johnson Medical School Newark/New Brunswick, NJ, USA Robert L. Johnson, MD, FAAP, is the Sharon and Joseph L. Muscarelle Endowed Dean, Professor of Pediatrics, and Director of the Division of Adolescent and Young Adult Medicine at Rutgers New Jersey Medical School. He is also the Interim Dean of the Robert Wood Johnson Medical School at Rutgers University. His clinical expertise and research focuses on adolescent physical and mental health, adolescent HIV, adolescent violence, adolescent sexuality, health equity, and family strengthening. Section Co-editor – Community Violence and Abuse Jennifer Langhinrichsen-Rohling Department of Psychological Sciences and Health Psychology University of North Carolina – Charlotte Charlotte, NC, USA Jennifer Langhinrichsen-Rohling, PhD, is Clinical Psychologist and Professor of Psychological Sciences and Health Psychology at the University of North Carolina – Charlotte. She has more than 30 years of experience in community-clinical research on intimate partner and family violence, including psychological, physical, and sexual violence, intergenerational abuse, and stalking. Her work includes more than 175 publications. She has facilitated capacity building for integrated health, trauma-informed care, and trauma-focused cognitivebehavioral therapy in healthcare settings, police departments, and schools. Section Co-editor – Intimate Partner Violence

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About the Section Editors

Stacie Schrieffer LeBlanc The UP Institute New Orleans, LA, USA Stacie Schrieffer LeBlanc, JD, Med, is Co-founder and CEO, The Up Institute, and President, American Professional Society on the Abuse of Children. For 29 years, she worked as a supervising prosecutor and as executive director of two child abuse nonprofits, the New Orleans CAC and Audrey Hepburn CARE Center. Ms. LeBlanc created Beyond Mandatory Reporting; Dear Parents; Teens, Sex, and the Law; and Painless Parenting. She teaches the CAST course at Tulane University and chairs the National No Hit Zone Committee. Section Co-editor – Maltreatment and Victimization of Children and Adolescents Sylvia A. Marotta-Walters Department of Counseling and Human Development The George Washington University Washington, DC, USA Sylvia A. Marotta-Walters, PhD, Med, is Professor of Counseling, Graduate School of Education and Human Development at George Washington University. Dr. Marotta-Walters’ research focus is on the spectrum of trauma and stress disorders, with a particular emphasis on the developmental consequences of trauma exposure and on diversity issues among exposed individuals and groups. She publishes and presents on trauma and resilience among adult survivors and is Associate Editor for the journal, Psychological Trauma: Theory, Research, Practice, and Policy. Section Co-editor – Adult Survivors of Abuse Mary Beth Quaranta Morrissey Global Health Care Innovation Management Center Fordham University New York, NY, USA Global Health Care Innovation Management Center Fordham University Gabelli School of Business West Harrison, NY, USA Mary Beth Quaranta Morrissey, PhD, MPH, JD, is a health and gerontological social work researcher and

About the Section Editors

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attorney concentrating in health and public health law. She holds fellow and adjunct faculty appointments in Fordham University’s Global Healthcare Innovation Management Center, Gabelli School of Business, and Graduate School of Social Service. Dr. Morrissey serves as senior advisor for health policy and ethics to the Finger Lakes Geriatric Education Center at the University of Rochester Medical Center. Section Co-editor – Older Adult and Elder Abuse Heather J. Risser Feinberg School of Medicine Northwestern University Chicago, IL, USA Heather J. Risser, PhD, is Assistant Professor in the Department of Psychiatry and Behavioral Sciences at Feinberg School of Medicine at Northwestern University. Dr. Risser has studied the effectiveness of parent training and interventions for children exposed to violence for more than 20 years. Her research focuses on parent training, mental health treatment for child victims of abuse, child abuse prevention, child welfare, and access to parenting and mental health promotion services for underserved children and families. Section Coeditor – Maltreatment and Victimization of Children and Adolescents Amy Russell Russell Consulting Specialists, LLC Vancouver, WA, USA Amy Russell, MSEd, JD, NCC, is the Principal Consultant and Trainer with Russell Consulting Specialists, LLC in Vancouver, Washington. Ms. Russell is a licensed attorney and a nationally certified counselor who has worked with victims of violence and trauma in several capacities. She has served as director of and consultant to several Children’s Advocacy Centers and has provided international training on child abuse investigations, interviews, and litigation. Section Co-editor – Maltreatment and Victimization of Children and Adolescents

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About the Section Editors

Marie Skov MS, is a PhD fellow in the Department of Psychology and Behavioral Sciences at Aarhus University in Denmark. Her research interests include sexual assault, rape myths, and survivors’ encounter with the medical and criminal justice systems. Ms. Skov has a special focus on how trauma-informed interventions can alter perceptions among groups of future professionals such as medical students and police trainees. Section Co-editor – Adult Sexual Harassment and Assault

Kevin Swartout Department of Psychology Georgia State University Atlanta, GA, USA Kevin Swartout, PhD, is Associate Professor of Psychology and Public Health at Georgia State University in Atlanta, GA, and has a courtesy appointment at the University of Texas at Austin. His research addresses trajectories and social correlates of violence and harassment across time, with the goal promoting safer organizations and communities. Dr. Swartout has received early-career awards from the International Society for Research on Aggression, the Southeastern Psychological Association, and Georgia State University. Section Coeditor – Adult Sexual Harassment and Assault Glenna Tinney United States Navy Alexandria, VA, USA Glenna Tinney, MSW, ACSW, DCSW, Captain, US Navy (Ret.), is a consultant on violence against women, social justice, environmental justice, and animal rights. As a social worker for more than 45 years, she worked primarily in violence against women and children. She served in the Navy for 24 years working with military families and managing worldwide family violence and sexual assault programs in the Department of Defense. In March 2013, President Obama’s White House selected Ms. Tinney as a Woman Veteran Champion of Change. Section Co-editor – Intimate Partner Violence

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Shelly M. Wagers Department of Criminology College of Arts and Sciences – Society, Culture, and Language University of South Florida – St. Petersburg St. Petersburg, FL, USA Shelly M. Wagers, PhD, is Assistant Professor of Criminology at the University of South Florida, St. Petersburg, and the Executive Director for the National Partnership to End Interpersonal Violence. Dr. Wagers has worked in the intimate partner violence field for more than 25 years, first, as an advocate, then as a law enforcement officer, and now as a scholar. Her research focuses on examining the relationship between power, control, and IPV, as well as developing evidence-based practices for IPV policies and programs. Section Co-editor – Intimate Partner Violence Javonda Williams School of Social Work The University of Alabama Tuscaloosa, AL, USA Javonda Williams, PhD, MSW, is Associate Professor and Associate Dean for Educational Programs and Student Services, School of Social Work, University of Alabama. Dr. Williams has extensive clinical experience with sexually abused children and adolescents. She has facilitated child abuse trainings for the Department of Human Resources, the Guardian Ad Litem Program, and several nonprofit agencies. Her areas of scholarship and research include trauma and resilience in children, and the provision of services for survivors of human trafficking. Section Co-editor - Maltreatment and Victimization of Children and Adolescents Rebecca Wilson Department of Psychology Georgia State University Atlanta, GA, USA Rebecca Wilson is a doctoral candidate in the Community Psychology Department at Georgia State University. Her research interests include examining social norms supportive of sexual violence, public health and

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economic policy prevention approaches to international violence against women, the impact of conflict on women, and the use of sexual violence as a tactic of war. Additionally, she has conducted research examining insurgent group behavior and counterterrorism policy. Section Co-editor – Adult Sexual Harassment and Assault

Contributors

Sara M. Abdulla Georgia State University, Atlanta, GA, USA Dylan Abrams John Jay College, New York, NY, USA The Graduate Center, City University of New York, New York, NY, USA Ana Abu-Rus Trauma Research Institute, Alliant International University, San Diego, CA, USA Alexis A. Adams-Clark Department of Psychology, University of Oregon, Eugene, OR, USA Randell Alexander University of Florida – Jacksonville, Jacksonville, FL, USA Georgia J. Anetzberger School of Medicine and Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, OH, USA Lisa P. Armistead Department of Psychology, Georgia State University, Atlanta, GA, USA Melissa Ashton Florida Council Against Sexual Violence, Tallahassee, FL, USA Ingunn Rangul Askeland Alternative to Violence, Oslo, Norway Norwegian Centre for Violence and Traumatic Stress Studies, NKVTS, Oslo, Norway Laura Austin Department of Psychology, Suffolk University, Boston, MA, USA Nicole Ayson University of California San Diego School of Medicine/Rady Children’s Hospital San Diego, San Diego, CA, USA Andia Azimi Department of Criminal Justice and Criminology, College of Criminal Justice, Sam Houston State University, Huntsville, TX, USA Julia Babcock Department of Psychology, University of Houston, Houston, TX, USA Nicola Barclay Nuffield Department of Clinical Neurosciences, Sleep and Circadian Neuroscience Institute (SCNi), Sir William Dunn School of Pathology, University of Oxford, Oxford, UK xlix

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Contributors

Veronica R. Barrios Family Science and Social Work, Miami University, Oxford, OH, USA Jessica Dym Bartlett Child Trends, Waltham, MA, USA Michael Baxter School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA Patricia Becker University of Delaware, Newark, DE, USA Aysenil Belger University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Duke-UNC Brain Imaging and Analysis Center, Durham, NC, USA Alexandra L. Bellis Fairfax, VA, USA Victoria Beltran University of South Florida, Tampa, FL, USA Demara B. Bennett Florida Institute of Technology, Melbourne, FL, USA Victoria E. Bennett Department of Psychology, University of Houston, Houston, TX, USA Gail Benton Sunnybrook Dentistry, Jackson, MS, USA Scott A. Benton University of Mississippi Medical Center, Jackson, MS, USA Alan Berkowitz Mount Shasta, CA, USA Ilana S. Berman Duke University School of Medicine, Durham, NC, USA Jacquelin Berman New York City Department for the Aging, New York, NY, USA Pearl S. Berman Indiana University of Pennsylvania, Indiana, PA, USA Sharon Bernards Centre for Addiction and Mental Health, Institute for Mental Health Policy Research, London, ON, Canada Theresa S. Betancourt Boston College School of Social Work, Boston, MA, USA Melissa S. Beyer The University of Memphis, Memphis, TN, USA Nancy Blaney Animal Welfare Institute, Washington, DC, USA Megan W. Blankenship Department of Medical and Clinical Psychology, Uniformed Services University, Bethesda, MD, USA Chelsea Blink Washington, DC, USA Melanie J. Bliss Thrive Center for Psychological Health, Adjunct Faculty, Emory University School of Medicine, Decatur, GA, USA Katherine W. Bogen Department of Psychiatry, Rhode Island Hospital, Providence, RI, USA Alex Bonagura John Jay College, New York, NY, USA The Graduate Center, City University of New York, New York, NY, USA

Contributors

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Lauren Bradel-Warlick Federal Bureau of Prisons, Sandstone, MN, USA Patricia Branco National Resource Center on Domestic Violence, Harrisburg, PA, USA Bonnie Brandl National Clearinghouse on Abuse in Later Life/End Domestic Abuse Wisconsin: the Wisconsin Coalition Against Domestic Violence, Madison, WI, USA Ernestine C. Briggs Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA Verena Wyvill Brown Children’s Healthcare of Atlanta, Atlanta, GA, USA Patricia Brownell Graduate School of Social Service, Fordham University, New York, NY, USA Rosalyn E. Brownlee University of Mississippi Medical Center, Jackson, MS, USA Tamika J. Bryant Children’s Healthcare of Atlanta, Atlanta, GA, USA Thema Bryant-Davis Pepperdine University, Los Angeles, CA, USA Jason Burnett Department of Internal Medicine, McGovern Medical School, UTHealth, Houston, TX, USA Jeffrey A. Butts John Jay College of Criminal Justice, The City University of New York, New York, NY, USA John Caffaro California School of Professional Psychology, Alliant International University, Los Angeles, CA, USA Cynthia Calkins John Jay College, New York, NY, USA Jacquelyn Campbell School of Nursing, Johns Hopkins University, Baltimore, MD, USA Roger A. Canaff Justice3D, New York, NY, USA Michael Brad Cannell School of Public Health, Dallas Regional Campus, The University of Texas Health Science Center at Houston, Houston, TX, USA Marissa S. Cantu Washington University School of Medicine, St. Louis, MO, USA Deborah M. Capaldi Oregon Social Learning Center, Eugene, OR, USA Thomas Caprio Finger Lakes Geriatric Education Center, University of Rochester Medical Center, Rochester, NY, USA Sandi Capuano Morrison IVAT – Institute on Violence, Abuse and Trauma, San Diego, MN, USA

lii

Contributors

Michele M. Carter Department of Psychology, American University, Bethesda, MD, USA Jonathan Caspi Family Science and Human Development, Montclair State University, Montclair, NJ, USA Kelly M. Champion Cadeus Behavioral Health, Rockville, MA, USA Shayna Cheek Duke University Medical Center, Durham, NC, USA Tiffany Chenneville University of South Florida, Tampa, FL, USA Elena Cherepanov Cambridge College, Boston, MA, USA Yu-Ling Chiu University of Illinois at Urbana-Champaign, Champaign, IL, USA Kirsten M. Christensen Department of Psychology, University of Massachusetts Boston, Boston, MA, USA Michelle Clayton Eastern Virginia Medical School/Children’s Hospital of The King’s Daughters, Norfolk, VA, USA Charlene Collibee Brown University, Providence, RI, USA R. Lorraine Collins Department of Community Health and Health Behavior, University at Buffalo, State University of New York, Buffalo, NY, USA Joanna Colrain Atlanta, GA, USA Lillian Comas-Díaz Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, DC, USA Lisa Conradi Chadwick Center for Children and Families, Rady Children’s Hospital – San Diego, San Diego, CA, USA Jon R. Conte Joshua Center on Child Sexual Abuse, University of Washington, Seattle, WA, USA Paola M. Contreras William James College, Newton, MA, USA Lauren Conway School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA Sarah L. Cook Department of Psychology, Georgia State University, Atlanta, GA, USA Elisabeth Corey Beating Trauma, Richmond, VA, USA Dewey G. Cornell Curry School of Education, University of Virginia, Charlottesville, VA, USA Karma Cottman Ujima Inc.: The National Center on Violence Against Women in the Black Community, Washington, DC, USA Tyler Counsil Zero Abuse Project, St. Paul, MN, USA

Contributors

liii

Christine A. Courtois Trauma Psychology and Treatment, Bethany Beach, DE, USA Elizabeth P. Cramer School of Social Work, Virginia Commonwealth University, Richmond, VA, USA Cailin Crockett Office of the Secretary of Defense Family Advocacy Program, U.S. Department of Defense, Alexandria, VA, USA Theodore P. Cross University of Illinois at Urbana-Champaign, Champaign, IL, USA Allison Crowe Department of Interdisciplinary Professions, East Carolina University, Greenville, NC, USA Carlos A. Cuevas Violence and Justice Research Laboratory, School of Criminology and Criminal Justice, Northeastern University, Boston, MA, USA Ashley S. D’Inverno Division of Violence Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA Hazel Da Breo Sweet Water Foundation, St. George’s, Grenada Sweet Water Foundation, Toronto, ON, Canada Critical Incident Stress Management Unit (CISMU), United Nations Department of Safety and Security, New York, NY, USA Chic Dabby Asian Pacific Institute on Gender-Based Violence, Oakland, CA, USA Linda L. Dahlberg Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA Leah E. Daigle Department of Criminology and Criminal Justice, Georgia State University, Atlanta, GA, USA Constance Dalenberg Trauma Research Institute, Alliant International University, San Diego, CA, USA Edessa David Feinberg School of Medicine, Northwestern University, Chicago, IL, USA Karol E. Dean Aurora University, Aurora, IL, USA Patrick H. Deleon Daniel K. Inouye Graduate School of Nursing and F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, MD, USA Brianna C. Delker Department of Psychology, Western Washington University, Bellingham, WA, USA Michelle L. Demaray Northern Illinois University, Dekalb, IL, USA Christine Descartes Department of Behavioural Sciences, The University of the West Indies, St. Augustine, Trinidad

liv

Contributors

Katelyn Donisch Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA Emily M. Douglas Monclair State University, Montclair, NJ, USA Ulester Douglas Men Stopping Violence, Atlanta, GA, USA Lynn Dowd University of Massachusetts Memorial Health Center, Worcester, MA, USA Margaret B. Drew University of Massachusetts School of Law, Dartmouth, MA, USA Vanessa Drew Elon University, Elon, NC, USA Howard Dubowitz School of Medicine, University of Maryland, Baltimore, MD, USA Melanie P. Duckworth Department of Psychology, University of Nevada, Reno, Reno, NV, USA Joan E. Durrant Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada Carmel Dyer Geriatric and Palliative Medicine at McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA Yvette Dzumaga The UP Institute, Newport News, VA, USA Christopher I. Eckhardt Department of Psychological Sciences, Purdue University, West Lafayette, IN, USA Miriam K. Ehrensaft Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA Diane Elmore Borbon Policy Program, UCLA-Duke University National Center for Child Traumatic Stress, Washington, DC, USA Cassandra Elverum Children’s Hospital of The King’s Daughters, Norfolk, VA, USA Ngozi Enelamah Boston College School of Social Work, Boston, MA, USA Tanya Erazo John Jay College of Criminal Justice – City University of New York, New York, NY, USA The Graduate Center at CUNY, New York, NY, USA Emelie Ernberg University of Gothenburg, Gothenburg, Sweden Joy Swanson Ernst Wayne State University School of Social Work, Detroit, MI, USA

Contributors

lv

Lianne Fuino Estefan Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA Kathleen Coulborn Faller School of Social Work, University of Michigan, Ann Arbor, MI, USA Boye Fang Department of Sociology and Anthropology, Sun Yat Sen University, Guangzhou, People’s Republic of China Danielle M. Farrell Yale University Child Study Center, New Haven, CT, USA Rita Farrell Zero Abuse Project, Fishers, MN, USA Alison Feigh Jacob Wetterling Resource Center, St. Paul, MN, USA Vincent J. Felitti Kaiser Permanente Medical Care Program, San Diego, CA, USA Marc V. Felizzi School of Social Work, Millersville University of Pennsylvania, Millersville, PA, USA Matthew D. Fetzer Criminal Justice, Shippensburg University, Shippensburg, PA, USA Bonnie S. Fisher School of Criminal Justice, University of Cincinnati, Cincinnati, OH, USA Lisa Aronson Fontes University of Massachusetts Amherst, Amherst, MA, USA Jessica L. Ford Baylor University, Waco, TX, USA Lori D. Frasier Department of Pediatrics, Center for the Protection of Children, Penn State Health Children’s Hospital, Penn State College of Medicine, Hershey, PA, USA Rae Anne Frey-Ho Fung Rogers Behavioral Health, U.S. Army/OIF Veteran, Milwaukee, WI, USA Patti A. Timmons Fritz University of Windsor, Windsor, ON, Canada Kristel-Ann Galarce Department of Psychology, University of Nevada, Reno, Reno, NV, USA James Garbarino Psychology Department, Loyola University Chicago, Chicago, IL, USA Olivia Garcia Casa de Esperanza: National Latin@ Network for Healthy Families and Communities, St. Paul, MN, USA Gretta Gardner Ujima Inc.: The National Center on Violence Against Women in the Black Community, Washington, DC, USA Megan R. Garza Healing Reflections Therapy, St. Louis, MO, USA Yasmin Gay Wake Forest School of Medicine, Winston Salem, NC, USA

lvi

Contributors

Robert Geffner Institute on Violence, Abuse and Alliant International University, San Diego, CA, USA April Gerlock University of Washington, School of Nursing, Seattle, WA, USA Alicia Sanchez Gill Washington, DC, USA Lee Giordano Men Stopping Violence, Atlanta, GA, USA Robyn L. Gobin Department of Community Health, University of Illinois at Urbana-Champaign, Urbana-Champaign, IL, USA D. Andrew Godfrey Department of Psychology, University of Houston, Houston, TX, USA Kelly Goggin Violence and Justice Research Laboratory, School of Criminology and Criminal Justice, Northeastern University, Boston, MA, USA Jonathan S. Goldner Rush University Medical Center, Chicago, IL, USA David B. Goldston Duke University Medical Center, Durham, NC, USA Jennifer M. Gómez Department of Psychology and Merrill Palmer Skillman Institute for Child and Family Development, Wayne State University, Detroit, MI, USA Alejandra Gonzalez Department of Psychology, The University of Akron, Akron, OH, USA Betsy P. Goulet University of Illinois Springfield, Springfield, IL, USA Angela R. Gover School of Public Affairs, University of Colorado Denver, Denver, CO, USA Amy Governale North Park University, Chicago, IL, USA Rachel Graber National Coalition Against Domestic Violence, Denver, CO, USA Kathryn Graham Centre for Addiction and Mental Health, Institute for Mental Health Policy Research, London, ON, Canada Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada National Drug Research Institute, Curtin University, Perth, Western Australia School of Psychology, Faculty of Health, Deakin University, Geelong, VIC, Australia Laurie M. Graham School of Social Work, University of Maryland, Baltimore, MD, USA James Granberry The University of North Carolina Charlotte, Charlotte, NC, USA Damion Grasso Department of Psychiatry, University of Connecticut School of Medicine, West Hartford, CT, USA

Contributors

lvii

Kelly Graves Kellin Foundation, Greensboro, NC, USA Michael B. Greene Rutgers University: School of Criminal Justice, Newark, NJ, USA Jessica M. Grosholz Department of Social Sciences, University of South Florida Sarasota-Manatee, Sarasota, FL, USA Kalynn C. Gruenfelder Department of Psychology, Georgia Southern University, Statesboro, GA, USA Shannon Guillot-Wright UTMB Health, Galveston, TX, USA Tamara A. Hamai Hamai Consulting, Palo Alto, CA, USA L. Kevin Hamberger Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, WI, USA Stephen Hargarten Comprehensive Injury Center, Medical College of Wisconsin, Milwaukee, WI, USA Nancy S. Harper Pediatric Emergency Medicine and Child Abuse, University of Minnesota, Minneapolis, MN, USA Shannon B. Harper Department of Sociology, Iowa State University, Ames, IA, USA Melanie D. Hetzel-Riggin School of Humanities and Social Sciences, Penn State Behrend, The Behrend College, Erie, PA, USA Richard E. Heyman Family Translational Research Group, New York University, New York, NY, USA Rosie Hidalgo Casa de Esperanza: National Latin@ Network for Healthy Families and Communities, St. Paul, MN, USA Melody Higgins School of Social Work, The University of Alabama, Tuscaloosa, AL, USA Sherika N. Hill Duke University, Durham, NC, USA Denise A. Hines George Mason University, Fairfax, VA, USA Tracy N. Hipp Department of Psychology, University of Memphis, Memphis, TN, USA Hilary B. Hodgdon The Trauma Center at Justice Resource Institute, Brookline, MA, USA Amy Holtzworth-Munroe Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA Elizabeth K. Hopper The Trauma Center at Justice Resource Institute, Brookline, MA, USA

lviii

Contributors

Alexandra G. Hosack Indiana University of Pennsylvania, Indiana, PA, USA Grace Huang Asian Pacific Institute on Gender-Based Violence, Seattle, WA, USA Tony Iezzi London Health Sciences Centre, London, ON, Canada Jada Ingalls Child Abuse Referral and Evaluation (CARE) Clinic, Sanford Children’s Hospital Fargo, Sanford Health, Fargo, ND, USA Per Isdal Alternative to Violence, Stavanger, Norway Martha Ishiekwene Department of Psychology, Georgia State University, Atlanta, GA, USA Sonia Ivancic University of South Florida, Tampa, FL, USA Shelly L. Jackson University of Virginia, Charlottesville, VA, USA Genna M. Jacobs School of Public Health, Georgia State University, Atlanta, GA, USA Cory Jewell Jensen CBI Consulting, Inc., Portland, OR, USA Shengse R. Jeong Northern Illinois University, Dekalb, IL, USA Lily J. Jiang Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA Catherine H. Johnson Guilford County Family Justice Center, Greensboro, NC, USA Dawn M. Johnson Department of Psychology, The University of Akron, Akron, OH, USA Rachel Johnson Education and Research, Zero Abuse Project, St. Paul, MN, USA Robert L. Johnson Rutgers Medical School and The Robert Wood Johnson Medical School, Newark/New Brunswick, NJ, USA Katherine Kafonek University of Delaware, Newark, DE, USA Nina Kane Center for Child and Family Health, Durham, NC, USA Niranjan S. Karnik Rush University Medical Center, Chicago, IL, USA Megan Kearns Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA Casey Keene National Resource Center on Domestic Violence, Harrisburg, PA, USA Kathleen Kendall-Tackett Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, TX, USA Roxanne Khan Psychology, University of Central Lancashire, PRESTON, UK

Contributors

lix

Mawia Khogali John Jay College of Criminal Justice – City University of New York, New York, NY, USA Cassandra Kisiel Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA Julia M. Kobulsky School of Social Work, College of Public Health, Temple University , Philadelphia, PA, USA Sara Kohlbeck Comprehensive Injury Center, Medical College of Wisconsin, Milwaukee, WI, USA Jamie S. Kondis Washington University School of Medicine, St. Louis, MO, USA Mary P. Koss University of Arizona, Tucson, AZ, USA Jessie L. Krienert Department of Criminal Justice Sciences, Illinois State University, Normal, IL, USA Teresa C. Kulig School of Criminology and Criminal Justice, University of Nebraska Omaha, Omaha, NE, USA Jennifer Kusz School of Criminology, Simon Fraser University, Burnaby, BC, Canada Raina V. Lamade University of Massachusetts Dartmouth, Dartmouth, MA, USA Lesley Lambo Concordia University, Montreal, QC, Canada Ashley L. Landers Department of Human Development and Family Science, Virginia Polytechnic Institute and State University, Falls Church, VA, USA Jennifer Langhinrichsen-Rohling Department of Psychological Sciences and Health Psychology, University of North Carolina – Charlotte, Charlotte, NC, USA Caroline LaPorte Attorney and Consultant (Descendant, Little River Band of Ottawa Indians), Miami, FL, USA Sadie E. Larsen Milwaukee VA Medical Center, Medical College of Wisconsin, Milwaukee, WI, USA Deana Lashley University of Florida – Jacksonville, Jacksonville, FL, USA Nicole V. Lasky Department of Criminology, Justice Studies and Global Security, Northeastern State University, Tahlequah, OK, USA Emma Lathan Clinical and Counseling Psychology Program, University of South Alabama, Mobile, AL, USA Timothy R. Lauger Department of Criminology and Criminal Justice, Niagara University, Lewiston, NY, USA Stacie Schrieffer LeBlanc The UP Institute, CEO, New Orleans, LA, USA

lx

Contributors

Gloria S. Lee Department of Pediatrics, Center for the Protection of Children, Penn State Health Children’s Hospital, Penn State College of Medicine, Hershey, PA, USA Sou Lee Southern Illinois University Carbondale, Carbondale, IL, USA Penny A. Leisring Quinnipiac University, Hamden, CT, USA Maria C. Lent University of Vermont, Burlington, VT, USA Patricia E. Lester University of California, Los Angeles (UCLA), Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA Michael Levittan UCLA Extension, Los Angeles, CA, USA Alicia F. Lieberman Department of Psychiatry and Child Trauma Research Program, University of California San Francisco, San Francisco, CA, USA Rachel E. Liebman Department of Psychology, Ryerson University, Toronto, ON, Canada Faculty of Health, York University, Toronto, ON, Canada Chris Lim School of Social Work, The University of Alabama, Tuscaloosa, AL, USA Sarah Lockwood Violence and Justice Research Laboratory, School of Criminology and Criminal Justice, Northeastern University, Boston, MA, USA Ashton M. Lofgreen Rush University Medical Center, Chicago, IL, USA TK Logan Department of Behavioral Science, University of Kentucky, Lexington, KY, USA Bente Lømo Alternative to Violence, Oslo, Norway Elise C. Lopez University of Arizona, Tucson, AZ, USA Greg Loughlin Men Stopping Violence, Atlanta, GA, USA Sabina Low T. Denny Sanford School of Social and Family Dynamics, Arizona State University, Phoenix, AZ, USA Yu Lu University of Oklahoma, Norman, OK, USA Arlene Macdonald UTMB Health, Galveston, TX, USA Rosemarie Lillianne Macias University of New Haven, West Haven, CT, USA Vicki J. Magley University of Connecticut, Storrs, CT, USA Priya E. Maharaj Mental Health Department, Gulf View Medical Centre, San Fernando, Trinidad Dominique A. Malebranche Lesley University, Cambridge, MA, USA

Contributors

lxi

Jessica E. Mandell University of Memphis, Memphis, TN, USA Jamie L. Manzer University of Delaware, Newark, DE, USA Sylvia A. Marotta-Walters Department of Counseling and Human Development, The George Washington University, Washington, DC, USA Andrea A. Massa Department of Psychological Sciences, Purdue University, West Lafayette, IN, USA Khalilah M. Mccants Daniel K. Inouye Graduate School of Nursing, Uniformed Services University, Bethesda, MD, USA Susan McCarter The University of North Carolina Charlotte, Charlotte, NC, USA Kristy L. McCray Department of Health and Sport Sciences, Otterbein University, Westerville, OH, USA Robyn McLaughlin Department of Pediatrics, IWK Health Centre, Halifax, NS, Canada Dalhousie University, Halifax, NS, Canada David McLeod Anne and Henry Zarrow School of Social Work, University of Oklahoma, Norman, OK, USA Anne Menard National Resource Center on Domestic Violence, Harrisburg, PA, USA James A. Mercy Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA Jillian S. Merrick Department of Psychology, University of Denver, Denver, CO, USA Jill T. Messing School of Social Work, Arizona State University, Phoenix, AZ, USA Stephen Messner Stephanie V. Blank Center for Safe and Healthy Children, Children’s Healthcare of Atlanta, Child Abuse Pediatrics, Emory University, Atlanta, GA, USA L. C. Miccio-Fonseca Clinic for the Sexualities, San Diego, CA, USA Madelyn Simring Milchman Private Practice, Psychology, Montalcir, NJ, USA Alisa Miller Department of Psychiatry, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA Erin C. Miller Newton-Wellesley Hospital, Newton, MA, USA Cindy Miller-Perrin Pepperdine University, Malibu, CA, USA Maria Minor Weill Cornell Medical College, New York, NY, USA

lxii

Contributors

Reese Minshew Trauma and Gender in Chicago, Chicago, IL, USA Danielle M. Mitnick Family Translational Research Group, New York University, New York, NY, USA Mary Beth Quaranta Morrissey Global Health Care Innovation Management Center, Fordham University, New York, NY, USA Global Healthcare Innovation Management Center, Fordham University Gabelli School of Business, West Harrison, NY, USA Elizabeth A. Mumford NORC at the University of Chicago, Bethesda, MD, USA Christopher M. Murphy Department of Psychology, University of Maryland, Baltimore County, Baltimore, MD, USA Christine E. Murray Department of Counseling and Educational Development, University of North Carolina at Greensboro (UNCG), Greensboro, NC, USA Kathryn J. Murray Duke University and The Center for Child and Family Health, Durham, NC, USA Kevin L. Nadal John Jay College of Criminal Justice – City University of New York, New York, NY, USA Brandi Naish Trauma Research Institute, Alliant International University, San Diego, CA, USA Angela J. Narayan Department of Psychology, University of Denver, Denver, CO, USA Nancy Nava Casa de Esperanza: National Latin@ Network for Healthy Families and Communities, St. Paul, MN, USA Danielle Nesi Loyola University Chicago, Chicago, IL, USA Patricia Châu Nguyễn John Jay College of Criminal Justice – City University of New York, New York, NY, USA Graduate School of Education and Information Science, University of California, Los Angeles, Los Angeles, CA, USA Adella Nikitiades Clinical Psychologist, Montefiore Medical Center/ Albert Einstein College of Medicine, Bronx, NY, USA Phyllis Holditch Niolon Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA Nkiru Nnawulezi Department of Psychology, University of Maryland, Baltimore County, Baltimore, MD, USA Laura K. Noll Department of Psychological Sciences, Northern Arizona University, Flagstaff, AZ, USA

Contributors

lxiii

Adedoyin Okanlawon University of Massachusetts Dartmouth, Dartmouth, MA, USA Lindsay Orchowski Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA Amy E. Ornstein Department of Pediatrics, IWK Health Centre, Halifax, NS, Canada Dalhousie University, Halifax, NS, Canada Ivonne Ortiz National Resource Center on Domestic Violence, Harrisburg, PA, USA Stéphanie Pache Center for Medicine, Health, and Society, Vanderbilt University, Nashville, TN, USA Heather T. Pane Seifert Center for Child and Family Health, Durham, NC, USA Kathleen A. Parks Department of Psychology, University at Buffalo, State University of New York, Buffalo, NY, USA Robert N. Parrish Salt Lake County District Attorney’s Office, Salt Lake City, UT, USA Dominic J. Parrott Department of Psychology, Georgia State University, Atlanta, GA, USA Sarah Passmore School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA Lauren Pederson University of Wisconsin-Madison, Madison, WI, USA Robin D. Perrin Pepperdine University, Malibu, CA, USA Robert J. Peters Zero Abuse Project, Fairmont, WV, USA Frank S. Pezzella John Jay College of Criminal Justice, CUNY, New York, NY, USA Linzy M. Pinkerton Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA Sara-Beth Plummer BASW Program, Rutgers, The State University of New Jersey, Camden, NJ, USA Jessica B. Pomerantz Department of Psychology and Women’s and Gender Studies Program, University of South Carolina, Columbia, SC, USA Chad Posick Department of Criminal Justice and Criminology, Georgia Southern University, Statesboro, GA, USA Jeanne J. Preisler Center for Family and Community Engagement, North Carolina State University, Raleigh, NC, USA

lxiv

Contributors

Theresa Prichard Florida Council Against Sexual Violence, Tallahassee, FL, USA Doris F. Pu University of Alabama at Birmingham, Birmingham, AL, USA Xavier Quinn Fenway Health, Boston, MA, USA Megan Radenhausen Department of Psychology, University of Nevada, Reno, Reno, NV, USA Marius Råkil Alternative to Violence, Oslo, Norway Holly Ramsey-Klawsnik Klawsnik & Klawsnik Associates, Canton, MA, USA Mary Lou Randour Animal Welfare Institute, Washington, DC, USA Lucinda A. Lee Rasmussen San Diego State University, School of Social Work, San Diego, CA, USA Ann Ratnayake Macy National Center for Child Abuse Statistics and Policy, Washington, DC, USA Joan A. Reid Criminology, University of South Florida St. Petersburg, St. Petersburg, FL, USA Shannon E. Reid Criminal Justice and Criminology College, University of North Carolina at Charlotte, Charlotte, NC, USA Dennis E. Reidy School of Public Health, Georgia State University, Atlanta, GA, USA Inês Carvalho Relva Department of Education and Psychology, Universidade de Trás-os-Montes e Alto Douro, Vila Real, Portugal Research from the Research Center in Sports Sciences, Health Sciences and Human Development (CIDESD), Vila Real, Portugal Karen Rice School of Social Work, Millersville University of Pennsylvania, Millersville, PA, USA Johnny Rice II Department of Criminal Justice, College of Behavioral and Social Sciences, Coppin State University, Baltimore, MD, USA Karen Rich Department of Social Work, Marywood University, Scranton, PA, USA Tara N. Richards School of Criminology and Criminal Justice, University of Nebraska Omaha, Omaha, NE, USA Edward Richer Children’s Healthcare of Atlanta, Pediatric Radiology, Emory University, Atlanta, GA, USA Logan N. Riffle Northern Illinois University, Dekalb, IL, USA Heather J. Risser Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

Contributors

lxv

Laura M. River Department of Psychology, University of Denver, Denver, CO, USA Karen A. Roberto Center for Gerontology, Virginia Tech, Blacksburg, VA, USA Christina M. Rodriguez University of Alabama at Birmingham, Birmingham, AL, USA Lindsey M. Rodriguez University of South Florida, Tampa, FL, USA Rebecca Rodriguez Casa de Esperanza: National Latin@ Network for Healthy Families and Communities, St. Paul, MN, USA Gimel Rogers F.I.R.E. Igniting Lives, San Diego, CA, USA Alan Rosenbaum Department of Psychology, Northern Illinois University, DeKalb, IL, USA Avina I. Ross University Health Services, SHARE (Sexual Harassment/Assault, Advising, Resources and Education), McCosh Health Center, Princeton University, Princeton, NJ, USA Emely Roy University of Windsor, Windsor, ON, Canada Amy Russell Russell Consulting Specialists, LLC, Vancouver, WA, USA William R. Saltzman University of California, Los Angeles (UCLA), Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA Elizabeth Rosa Santiago Center for Safety and Change, New City, NY, USA Daniel G. Saunders University of Michigan, Ann Arbor, MI, USA Lameace Sayegh University of South Alabama, Mobile, AL, USA Tracy Sbrocco Department of Medical and Clinical Psychology, Uniformed Services University, Bethesda, MD, USA Dawn Scaff Children’s Hospital of The King’s Daughters, Norfolk, VA, USA Jennifer A. Scarduzio University of Kentucky, Lexington, KY, USA Mallory Schneider Clinical and Counseling Psychology Program, University of South Alabama, Mobile, AL, USA Sarah E. O. Schwartz Department of Psychology, Suffolk University, Boston, MA, USA Daniela M. Scotto Global Psychiatric Epidemiology Group, Columbia University – New York State Psychiatric Institute, New York, NY, USA Christine S. Sellers School of Criminal Justice and Criminology, Texas State University, San Marcos, TX, USA

lxvi

Contributors

Candice Selwyn Department of Community Mental Health Nursing, University of South Alabama, Mobile, AL, USA Daniel C. Semenza Department of Sociology, Anthropology, and Criminal Justice, Rutgers University, Camden, NJ, USA Josephine Vasquez Serrata Serrata Consulting Inc., Austin, TX, USA Meghan Shanahan Maternal and Child Health Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Amber L. Shipman Eastern Virginia Medical School/Children’s Hospital of The King’s Daughters, Norfolk, VA, USA Joann Wu Shortt Oregon Social Learning Center, Eugene, OR, USA June Simon Joshua Center on Child Sexual Abuse, University of Washington, Seattle, WA, USA Pete Singer Zero Abuse Project, St. Paul, MN, USA Care in Action Minnesota, Oakdale, MN, USA Advanced Trauma Consulting, Oakdale, MN, USA Jo Anne Sirey Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA Amy M. Smith Slep Family Translational Research Group, New York University, New York, NY, USA Judith R. Smith School of Social Services, Fordham University, New York, NY, USA Alexandra L. Snead Department of Psychology, University of Houston, Houston, TX, USA Chelsea M. Spencer Family Studies and Human Services, Kansas State University, Manhattan, KS, USA Ginny Sprang University of Kentucky, Lexington, KY, USA Center on Trauma and Children, Lexington, KY, USA Suzanne Starling University of California San Diego School of Medicine/Rady Children’s Hospital San Diego, San Diego, CA, USA Sandra M. Stith Family Studies and Human Services, Kansas State University, Manhattan, KS, USA Shelby Stohlman Clinical and School Psychology, University of Virginia, Charlottesville, VA, USA Jane Straub Zero Abuse Project, St. Paul, MN, USA

Contributors

lxvii

Jacqueline Strenio Department of Economics, Southern Oregon University, Ashland, OR, USA Jim Struve Salt Lake City, UT, USA Lauren A. Stutts Department of Health and Human Values, Davidson College, Davidson, NC, USA Laura C. Stymiest Department of Pediatrics, IWK Health Centre, Halifax, NS, Canada Dalhousie University, Halifax, NS, Canada Kelly M. Sullivan Department of Psychiatry and Behavioral Sciences, Duke University Medical Center and Center for Child and Family Health, Durham, NC, USA Monica H. Swahn School of Public Health, Georgia State University, Atlanta, GA, USA Suzanne C. Swan Department of Psychology and Women’s and Gender Studies Program, University of South Carolina, Columbia, SC, USA Kevin Swartout Department of Psychology, Georgia State University, Atlanta, GA, USA Jason Szkola John Jay College of Criminal Justice, The City University of New York, New York, NY, USA Elizabeth M. Tant Policy Program, UCLA-Duke University National Center for Child Traumatic Stress, Durham, NC, USA Nicholas Tarantino Brown University, Providence, RI, USA Bruce G. Taylor NORC at the University of Chicago, Bethesda, MD, USA Elizabeth A. Taylor Department of Sport and Recreation Management, Temple University, Philadelphia, PA, USA Pamela B. Teaster Center for Gerontology, Virginia Tech, Blacksburg, VA, USA Jeff R. Temple UTMB Health, Galveston, TX, USA Stacey S. Tiberio Oregon Social Learning Center, Eugene, OR, USA Glenna Tinney United States Navy, Alexandria, VA, USA Claire S. Tomlinson Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA Elizabeth D. Torres UTMB Health, Galveston, TX, USA Amanda C. Toumayan The University of Memphis, Memphis, TN, USA Sarah Treves-Kagan Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA

lxviii

Contributors

Valerie Trull School of Social Work, The University of Alabama, Tuscaloosa, AL, USA Angela M. Tunno Duke University Medical Center, National Center for Child Traumatic Stress, and Center for Child and Family Health, Durham, NC, USA Heather A. Turner Crimes against Children Research Center (CCRC) and Department of Sociology, University of New Hampshire, Durham, NH, USA Matthew Valasik Department of Sociology, Louisiana State University, Baton Rouge, LA, USA Rob (Roberta) Valente National Coalition Against Domestic Violence, Denver, CO, USA Brian Van Buren Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Frank E. Vandervort University of Michigan, Ann Arbor, MI, USA Viola Vaughan-Eden Ethelyn R. Strong School of Social Work, Norfolk State University, Norfolk, VA, USA Victor I. Vieth Education and Research, Zero Abuse Project, St. Paul, MN, USA Erin Wade Stephanie V. Blank Center for Safe and Healthy Children, Children’s Healthcare of Atlanta, Child Abuse Pediatrics, Emory University, Atlanta, GA, USA Shelly M. Wagers Department of Criminology, College of Arts and Sciences – Society, Culture, and Language, University of South Florida – St. Petersburg, St. Petersburg, FL, USA Jeffrey A. Walsh Department of Criminal Justice Sciences, Illinois State University, Normal, IL, USA Wendy A. Walsh University of New Hampshire, Durham, NH, USA Michelle G. K. Ward Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada Sujata Warrier Battered Women’s Justice Project, Minneapolis, MN, USA Carole Warshaw National Center on Domestic Violence, Trauma and Mental Health, Chicago, IL, USA Department of Psychiatry, University of Illinois, Chicago, IL, USA Aliya R. Webermann Department of Psychology, University of Maryland, Baltimore County, Baltimore, MD, USA Neil Websdale Family Violence Center, School of Social Work, Watts College of Public Service and Community Solutions Arizona State University, Phoenix, AZ, USA

Contributors

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Samantha Wells Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada Centre for Addiction and Mental Health, Institute for Mental Health Policy Research, Toronto, ON, Canada Department of Psychiatry, University of Toronto, Toronto, ON, Canada Department of Epidemiology and Biostatistics, Western University, London, ON, Canada School of Psychology, Deakin University, Geelong, VIC, Australia Carolyn M. West University of Washington, Tacoma, WA, USA Wendy Wheaton University of Massachusetts, Amherst, Amherst, MA, USA Jacquelyn W. White Department of Psychology College of Arts and Sciences, University of North Carolina at Greensboro, Greensboro, NC, USA Nicole Wilkes School of Criminal Justice, University of Cincinnati, Cincinnati, OH, USA Javonda Williams School of Social Work, The University of Alabama, Tuscaloosa, AL, USA Rebecca A. Wilson Department of Psychology, Georgia State University, Atlanta, GA, USA Emily D. Wolodiger Rush University Medical Center, Chicago, IL, USA Elsie Yan Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hong Kong, Hong Kong Nada Yorke Yorke Consulting, Sequim, WA, USA Mieko Yoshihama University of Michigan School of Social Work, Ann Arbor, MI, USA Gabriela A. Zapata-Alma National Center on Domestic Violence, Trauma and Mental Health, Chicago, IL, USA School of Social Service Administration, The University of Chicago, Chicago, IL, USA Alexandra I. Zelin University of Tennessee at Chattanooga, Chattanooga, TN, USA Caron Zlotnick Warren Alpert Medical School at Brown University, Providence, RI, USA Butler Hospital, Providence, RI, USA

Section I Interpersonal Violence and Abuse Across The Lifespan: Foundations and Perspectives Robert Geffner, Jacquelyn W. White, L. Kevin Hamberger, Alan Rosenbaum, Viola Vaughan-Eden, and Victor I. Vieth

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Fundamentals of Understanding Interpersonal Violence and Abuse Integrating Research, Practice, Advocacy, and Policy to Connect Agendas and Forge New Directions Jacquelyn W. White and Robert Geffner

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Commonalities and Dynamics Across All Forms of Interpersonal Violence . . . . . . . . . . . . . . . . . . . Recurrent Themes Across All Types of Interpersonal Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Developmental Perspective: Family Dynamics, Adverse Childhood Experiences, Poly-victimization, and Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intersectionality, Status, Power, and Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cultural Issues and Special Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Common Risk and Protective Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Increasing Awareness: The Handbook of Interpersonal Violence and Abuse Across the Lifespan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definitions, Theories, and Scope of Types of Interpersonal Violence . . . . . . . . . . . . . . . . . . . . . . . Systems Involved in Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intervention Approaches and Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevention Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Controversial Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Organizing to Connect Agendas: History of the National Partnership to End Interpersonal Violence Across the Lifespan (NPEIV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Action: Call for Integrating Research, Practice, Advocacy, and Policy . . . . . . . . . . . . . . . . . . . . . . . . . National Plan to Reduce Interpersonal Violence and Abuse Across the Lifespan . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. J. W. White Department of Psychology College of Arts and Sciences, University of North Carolina at Greensboro, Greensboro, NC, USA e-mail: [email protected] R. Geffner (*) Institute on Violence, Abuse and Alliant International University, San Diego, CA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_303

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Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Abstract

The present chapter provides an overview of the Handbook of Interpersonal Violence and Abuse Across the Lifespan as a call for awareness/education, organizing, and action in integrating the various forms of interpersonal violence and abuse across the lifespan. We first briefly discuss the overlap of all forms of interpersonal violence and abuse. We then examine an approach to research, practice, advocacy, and policy regarding interpersonal violence rooted in a developmental biopsychosocial framework, with an emphasis on the importance of adverse childhood experiences and their traumatic effects. The goals of the Handbook are then described, including controversial as well as timely issues, with an overview of over 200 chapters in the 5 volumes. Because the Handbook is a product of the National Partnership to End Interpersonal Violence Across the Lifespan (NPEIV), the history of NPEIV is described as a mechanism for organizing and connecting agendas. The chapter concludes with a call for greater integration of research, policy, practice, and advocacy such that interpersonal violence and abuse can be reduced globally because it affects more people and causes more damage than wars, diseases, and other epidemics combined. Keywords

Interpersonal violence · Silos · Commonalities · Integrating interpersonal violence and abuse · Lifespan · Intersectionality · Connecting agendas · Prevention · Biopsychosocial · Social ecological framework · NPEIV · Adverse Childhood Experiences · Poly-victimization

Introduction Interpersonal violence is ubiquitous in the lives of many people, all too often as victims, perpetrators, and/or witnesses, firsthand or in media reports. Furthermore, it is rare that just one form of interpersonal violence is experienced, a concept known as poly-victimization. For most, there is an intertwining of experiences and/or observations across the lifespan in multiple venues, including the home, school, community, workplace, social service and justice agencies, military, faith communities, and sports venues. In childhood it may take the form of neglect and/or physical, psychological, or sexual abuse. In adolescence, young people may experience bullying, dating violence, or sexual assault committed by peers, parents, or other adults. These forms of violence continue into the adult years as intimate partner violence, workplace harassment, sexual assault, and other types of assault, often extending into the later years of life in the form of elder abuse. What is evident is that there is no time in one’s life that one is not at risk for interpersonal violence and abuse nor is there a context in which there is no risk.

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Thus, there is an urgency to answer the question of why this is the case because these types of interpersonal violence and abuse have become major public health and social justice epidemics globally. Unfortunately, answering this question has been stifled by standard practices in the field of interpersonal violence for decades, which has resulted in silos of knowledge and practice. Thus, the Handbook of Interpersonal Violence and Abuse Across the Lifespan has been written to update our knowledge, research, experiences, and practices related to interpersonal violence and abuse, and to encourage new policies, research, and practices that eliminate the artificial silos and other barriers to actually implementing change in order to reduce and eventually end these epidemics worldwide. Current practice in the field of interpersonal violence fosters fragmentation and lack of communication, often resulting in a lack of transfer of knowledge. Furthermore, there are disconnects between what we know based on research and practice, the lived experiences of victims, and institutional and public policies designed to address the problems. There are advocacy and funding organizations, researchers, and journals as well as local, state, national, and international policies that focus on a specific form of interpersonal violence, but rarely do they have a collaborative focus on all the types of interpersonal violence and how they overlap and connect across the lifespan. However, there is growing recognition that the complexity of interpersonal violence requires interdisciplinary alliances across many sectors, including health care, criminal justice, mental health, education, business, and media, and across many approaches, including science, practice, advocacy, and policy (Grych & Swan 2012; Koss et al. 2011; White et al. 2011). The Centers for Disease Control and Prevention’s (CDC) Connecting the Dots is one example of a national effort to identify commonalities in the United States (Wilkins et al. 2014). Connecting the Dots is an online resource that allows users to understand more fully the shared risk and protective factors across multiple forms of violence. The present chapter briefly discusses the Handbook as a call for: (1) awareness/ education, (2) organizing, and (3) action in integrating the various forms of interpersonal violence and abuse across the lifespan. The chapter is divided into four sections. The first section makes the case for the need to integrate by briefly discussing the overlap of all forms of interpersonal violence and abuse, based on a developmental biopsychosocial ecological framework that emphasizes intersecting spheres at all levels of the social ecology that affects individuals, relationships, social networks, communities, and cultural practices. The next section identifies recurrent themes that have emerged in research and practice, and are evident within each level of the social ecology, that further document the commonalities across various forms of interpersonal violence. Although not an exhaustive list, these include a developmental perspective that addresses family dynamics with a focus on adverse childhood experiences, trauma and trauma-informed care, poly-victimization, power and control, intersectionality, historical trauma, similar risk and protective factors, and cultural practices that are key factors in violence which may also be opportunities for successful intervention and prevention. In the next section, we suggest that the Handbook offers a unique contribution to education and awareness by providing readers an opportunity to learn more about the

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scope of the field, see the interconnections, and garner insight into next steps. The Handbook is a product of the National Partnership to End Interpersonal Violence Across the Lifespan (NPEIV); thus, the third section of the chapter describes the evolution of NPEIV as a mechanism for organizing and connecting agendas. The final section of the chapter concludes with a call for greater integration of research, policy, practice, and advocacy, based on recommendations gleaned from the various Handbook chapters, as well as the National Plan to End Interpersonal Violence Across the Lifespan, another product of NPEIV. Relevant examples are presented.

Commonalities and Dynamics Across All Forms of Interpersonal Violence There are several vantage points from which to view interpersonal violence, each valuable, but none capable of mapping out the entire domain on its own. These perspectives include type of violence (physical, sexual, psychological), developmental stage (childhood, adolescence, adulthood, older adulthood), context (family, workplace, school, community, etc.), victim and perpetrator perspectives, and level of analysis, which may be individual, dyadic, family, community, or societal/cultural. The latter includes discussions of power and control, as well as gender, patriarchy, and race. Additionally, each of these has been viewed from a public health perspective, as well as human rights and social justice views (▶ Chap. 4, “Examining Interpersonal Violence from a Trauma-Informed and Human Rights Perspective,” by Graves and Gay ▶ Chap. 3, “A History of Interpersonal Violence: Raising Public Concern,” by Pasche). Various theoretical camps have also weighed in to provide explanations of violence, including intrapsychic, evolutionary, social learning, social information processing, cognitive-developmental, victim-precipitation, feminist, sociocultural, and biosocial theories, as well as a number of multifactor theories (Lopez Levers 2012; White & Kowalski 1998). Other issues that can serve as a basis for examining commonalities across types of violence include adverse childhood experiences, poly-victimization, and acute and complex trauma. Grasping the scope of interpersonal violence phenomena and issues can be a daunting task; this underscores the need for a framework from which to see the “big picture.” We suggest that a developmental biopsychosocial approach offers just such a vantage point. This approach allows for examining how the various levels of the social ecology intersect to affect all forms of interpersonal violence (see Fig. 1). At the individual level, the focus is on the person and the identification of individual attributes, such as a genetic predisposition for violence, a need for power and control, or psychopathy, that increase the risk of becoming a victim or perpetrator. At the dyadic or interactional level, the focus is on relationship factors, such as any power differential between victim and perpetrator or family conflict resolution styles between a parent and a child. At the community level, various institutions, such as schools, the military, faith communities, and the workplace,

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especially their policies and procedures, can be examined as locations for interpersonal violence, as well as locations for violence prevention. Finally, at the system level factors such as patriarchy, sexism, racism, and other forms of oppression are considered as mechanisms that create institutions and cultural practices that foment and reinforce the use of violence and abuse at the community and/or societal levels (Anderson 2005; ▶ Chap. 80, “Microaggressions and Implicit Biases: Rooted in Structural Racism and Systemic Oppression,” by Khogali, Nguyen, and Erazo). The various vantage points offered by the developmental biopsychosocial approach overlap and complement each other, yielding a deeper insight into the complexities of interpersonal violence. This results in new perspectives that can guide more effective research, practice, advocacy, and policy. The series of Venn diagrams described below present examples of some of these opportunities. Figure 2

Fig. 1 Social ecological approach. (Modified from Bronfenbrenner 1977)

Fig. 2 Integrating across types of interpersonal violence and abuse across time

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illustrates how multiple forms of violence across time and relationships can be usefully considered. At a glance, the possibility of an individual experiencing different types of violence simultaneously or at different points in time is apparent. Furthermore, the interpersonal violence can take on various forms, including psychological, sexual, or physical, or a combination. It is also recognized that the risk and protective factors, as well as consequences, are likely moderated by the multiple intersecting features of one’s identity. Additionally, these experiences may accumulate across time. When one has experienced multiple types of violence, which is much more common than is often recognized, this is referred to as poly-victimization (Finkelhor et al. 2007; ▶ Chap. 176, “Impact of Childhood Maltreatment and Polyvictimization on Adult Revictimization,” by Duckworth, Iezzi, Radenhausen, and Galarce; ▶ Chap. 189, “Polyvictimization and Elder Abuse,” by Teaster and Ramsey-Klawsnik) and often results in a cascade of deleterious effects across time (Repetti et al. 2002). Figure 3 presents a version of the socio-ecological framework that illuminates another way to think about commonalities and overlaps that may inspire new ways to think about the complex dynamics of interpersonal violence. This figure makes the point that there is always a dynamic interaction between the victim and perpetrator within a situation that is nested within the context of the influence of their family and friends/peers/coworkers, as well as the larger social environment. Additionally, individuals may be both a victim and a perpetrator (▶ Chap. 79, “Commonalities and Overlap Between Victims and Offenders,” by Posick and Gruenfelder). Another view of the contextual developmental model can be seen in Fig. 4. It focuses on specific factors that research has identified as affecting victimperpetrator dynamics, including genetics, personality, relationship dynamics, various perceptions, family-of-origin, and the context (adapted from White & Kowalski 1998). This indicates the complex nature of the overlap and intersection of various dynamics that often occur in these situations. A failure to recognize such interplay can lead to inappropriate interventions that may be Fig. 3 Putting it all together: A socio-ecological framework

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Fig. 4 A contextual developmental model

counterproductive for all parties. For example, research has shown that women and men have different perceptions of a person’s sexual intentions, and these are influenced by context, such as a dating situation or the use of alcohol (George et al. 2006), as well as by personality factors, such that men displaying higher levels of narcissism, hostile masculinity, and impulsivity are more likely to misperceive a woman’s sexual intent (Wegner and Abbey 2016). Such an intersection between personality, women and men’s differing perceptions of and expectations for a social interaction, and alcohol affect the likelihood for sexual assault.

Recurrent Themes Across All Types of Interpersonal Violence When reviews of the research on the various types of interpersonal violence are considered together, recurrent themes become obvious and reveal insights into the commonalities linking its various forms. Although the various themes are addressed in depth in various Handbook chapters, some elaboration is warranted here. These themes include: a developmental perspective with a focus on family dynamics and adverse childhood experiences; trauma and trauma-informed approaches, including historical trauma; poly-victimization; power and control related to status within a relationship as well as within a larger social hierarchy; intersectionality; cultural practices; and risk and protective factors.

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Developmental Perspective: Family Dynamics, Adverse Childhood Experiences, Poly-victimization, and Trauma A developmental perspective includes historical trauma, the intergenerational transfer of violence and abuse, and the cumulative effects of witnessing and/or exposure to violence (i.e., adverse childhood experiences) (Felitti et al. 1998; ▶ Chap. 5, “Adverse Childhood Experiences: Past, Present, and Future,” by Hamai and Felitti). Developmental considerations, especially the cumulative effects of repeated experiences with various forms of interpersonal violence, amplify a lifespan perspective. Based upon research during the past few decades, it has become clear that a biopsychosocial approach is necessary (e.g., ▶ Chap. 103, “Neuropsychological and Psychophysiological Correlates of Intimate Partner Violence,” by Godfrey, Bennett, Snead, and Babcock; Rosenbaum et al. 1997) to integrate the various forms of interpersonal violence and abuse across the lifespan. For too long, most of the different types of interpersonal violence and abuse have focused on psychosocial aspects and effects. However, since the later 1990s, the physiological and neurobiological aspects have become more integrated into our conceptualization and approaches in dealing with intervention and prevention for child abuse (e.g., ▶ Chap. 63, “Neurobiological Consequences of Child Maltreatment,” by Belger; Perry 2001), intimate partner violence (e.g., Rosenbaum et al. 1997), sexual trauma (▶ Chap. 149, “Health and Mental Health Consequences from Sexual Trauma Victimizations,” by Bliss), and adult health in more general terms (e.g., Felitti et al. 1998; ▶ Chap. 5, “Adverse Childhood Experiences: Past, Present, and Future” by Hamai & Felitti). As we have learned more about adverse childhood experiences (ACEs) research coordinated by Kaiser Hospital in California and the Centers for Disease Control and Prevention (see ▶ Chap. 5, “Adverse Childhood Experiences: Past, Present, and Future,” by Hamai and Felitti), it has become clear that what occurs in childhood can have significant psychological, social, and physiological effects on the person throughout their lifespan (e.g., ▶ Chap. 175, “Adult Sequelae of Childhood Interpersonal Violence,” by Minshew). The number of ACEs is one of the strongest predictors of all forms of interpersonal violence, medical diseases, and social and behavioral problems. Childhood trauma disrupts neurobiological development, impairs cognitive and psychological functioning, and leads to more at-risk health behaviors, social and behavioral problems, as well as medical diseases and dysfunction. These factors can then lead to early death. It is much more likely that a child or adolescent who experiences one type of abusive experience is going to experience multiple types of traumatic experiences at the same time or later in their development (i.e., polyvictimization and re-traumatization) (e.g., ▶ Chap. 137, “Poly-victimization: The Co-occurrence of Intimate Partner Violence with Other Forms of Aggression,” by Bradel-Warlick and Rosenbaum; Finkelhor et al. 2007; ▶ Chap. 176, “Impact of Childhood Maltreatment and Polyvictimization on Adult Revictimization,” by Iezzi, Radenhausen, and Galarce; ▶ Chap. 189, “Polyvictimization and Elder Abuse,” by Teaster & Ramsey-Klawsnik).

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Thus, experiencing multiple forms of adverse childhood experiences and interpersonal violence at various developmental stages throughout the lifespan does not just increase proportionally with each added victimization, but the traumatic effects and likely symptoms are magnified synergistically (e.g., Putnam et al. 2013). The importance then of taking a trauma-informed perspective cannot be overemphasized (e.g., ▶ Chap. 49, “Correlations Among Childhood Abuse and Family Violence, Prevention, Assessment, and Treatment from a Trauma-Focused Perspective,” by Felizzi and Rice; ▶ Chap. 4, “Examining Interpersonal Violence from a TraumaInformed and Human Rights Perspective,” by Graves and Gay; ▶ Chap. 6, “TraumaInformed Systems of Care,” by Rich and Garza). These issues and approaches are emphasized throughout this Handbook.

Intersectionality, Status, Power, and Control An intersectionality lens focuses attention on a person’s location in a social hierarchy, a location defined by multiple aspects of one’s identity, based on factors such as age, sex, race, ethnicity, sexual orientation, gender identity, disability status, socioeconomic status, and cultural experiences. This lens reveals the role of power and control in all forms of interpersonal violence across the lifespan from child abuse to elder abuse. It also offers insight into the foundational role of beliefs about gender as revealed in patriarchal values that suggest men have the right to dominate women, as research has shown it is an attitude associated with intimate partner violence and sexual assault (e.g., ▶ Chap. 95, “Feminist Perspectives of Intimate Partner Violence and Abuse (IPV/A),” by Becker, Kafonek, and Manzer; ▶ Chap. 143, “Rape Persists,” by Cook, Hipp, and Wilson; ▶ Chap. 105, “Intersectionality and Intimate Partner Violence and Abuse: IPV and People with Disabilities,” by Cramer, Plummer, and Ross). Hate crimes and bullying, forms of violence toward ethnic minorities, non-cis-gendered persons, immigrants, and persons with disabilities, can also be understood through the intersectionality lens (▶ Chap. 111, “The Intersectionality of Intimate Partner Violence in the Black Community,” by Rice, West, Cottman, and Gardner; ▶ Chap. 104, “Inclusion and Exclusion: Intersectionality and Gender-Based Violence,” by Warrier). The issues of power and control and the abusive use of power are the foundational issues underlying all aspects of interpersonal violence, and these surfaced again in the #MeToo movement and in 2020 with the Black Lives Matter movement and protests about violence against Black men and women by police worldwide.

Cultural Issues and Special Populations Numerous chapters within each part address cultural issues as a key aspect of dealing with interpersonal violence and abuse (e.g., ▶ Chap. 178, “The Tapestry of Identity: Understanding Intersectionality Within Victimization Experiences, Consequences, and Treatment of Adult Survivors of Abuse,” by Lockwood, Goggin, and Cuevas;

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▶ Chap. 110, “Gender-Based Violence and Culturally Specific Advocacy in Asian and Pacific Islander Communities,” by Dabby and Yoshihama; ▶ Chap. 58, “Cultural Competence in the Field of Child Maltreatment,” by Fontes; ▶ Chap. 153, “The Cultural Context of Sexual Assault and Its Consequences Among Ethnic Minority Women,” by Gobin and Gomez; ▶ Chap. 111, “The Intersectionality of Intimate Partner Violence in the Black Community,” by Rice, West, Cottman, and Gardner; ▶ Chap. 109, “Intimate Partner Violence Among Latina Survivors: Unique Considerations, Strategies, and Opportunities,” by Rodriguez, Serrata, Macias, Hidalgo, Nava, and Garcia; ▶ Chap. 34, “The People in Your Neighborhood: Working with Sexual and Gender Minority Youth as Victims of Sexual Violence,” by Russell). Several chapters focus on specific vulnerable populations, such as people with disabilities (e.g., ▶ Chap. 105, “Intersectionality and Intimate Partner Violence and Abuse: IPV and People with Disabilities,” by Cramer et al.; ▶ Chap. 155, “Sexual Abuse Among Individuals with Disabilities,” by Stutts), sexual orientation and transgender issues (e.g., ▶ Chap. 156, “Sexual Violence among Sexual and Gender Minorities,” by Beyer, Toumayan, and Hipp; ▶ Chap. 106, “Intimate Partner Abuse in Lesbian, Gay, Bisexual, Queer, Transgender and Two-Spirit (LGBQ/T and TS) Communities,” by Miller, Quinn, and Rosa Santiago), immigrants (e.g., ▶ Chap. 154, “Unsafe Sanctuary: Immigrants of Color Victims of Sexual Abuse,” by ComasDiaz; ▶ Chap. 108, “How Domestic Violence Impacts Immigrant Victims,” by Huang), older adults (▶ Chap. 193, “Caregiving and Elder Abuse: A Complex Relationship,” by Anetzberger; ▶ Chap. 185, “Intimate Partner Violence in Later Life,” by Crockett and Brandl; ▶ Chap. 186, “Sexual Victimization of the Elderly: An Examination of the Emergent Problem,” by Krienert and Walsh), diverse families (e.g., ▶ Chap. 174, “Lifespan and Intergenerational Promotive and Protective Factors Against the Transmission of Interpersonal Violence in Diverse Families,” by Narayan, Lieberman, Merrick, and River), and tribal communities (e.g., ▶ Chap. 107, “Intimate Partner Violence in Tribal Communities: Sovereignty, Self-Determination, and Framing,” by LaPorte). As noted above, cultural issues have taken on even more significance with the greater understanding about historical racial trauma, oppression and violence against Black men and women, Latinx, indigenous populations, and other people of color globally (e.g., see ▶ Chap. 8, “Historical and Contemporary Racial Trauma Among Black Americans: Black Wellness Matters,” by Rogers and Bryant-Davis).

Common Risk and Protective Factors The field becomes enriched when common risk and protective factors predictive of interpersonal violence are identified. Consideration of all these perspectives permits a clearer examination of the co-occurrence of various types of victimization and perpetration, as well as the possibility of being a victim and later becoming a perpetrator to others. These may include a history of family violence, social isolation, patriarchal values and beliefs, a need for power and dominance, history of alcohol and substance abuse, stress, and higher status in a relationship. Victimization

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during childhood, as discussed above, is a consistent predictor of further victimization as well as a strong predictor of perpetration. Likewise, social isolation contributes to the risk of victimization of children, spouses, and the elderly, something that has become evident during the COVID-19 pandemic (e.g., ▶ Chap. 133, “Feminist Perspectives on Disaster, Pandemics, and Intimate Partner Violence,” by Drew; ▶ Chap. 196, “Intersectionality of Race, Ethnicity, and Culture in Neglect, Abuse, and Violence Against Older Persons: Human Rights, Global Health, and Systems Approaches in Pandemics,” by Morrissey, Brownell, and Caprio; ▶ Chap. 77, “Responding to Child Abuse During a Pandemic,” by Vieth, Peters et al.). Lower status may be associated with increased risk for victimization via various attributes, such as age, disability status, gender, or other indicators of position in the social hierarchy, as discussed above.

Increasing Awareness: The Handbook of Interpersonal Violence and Abuse Across the Lifespan This Handbook addresses the fragmentation discussed above and serves as an umbrella, with contributing authors representing practitioners, advocates, policymakers, and researchers who are or will be leaders in their respective fields. Authors provide readers an opportunity to delve deeply into issues about specific forms of interpersonal violence while providing opportunities to see connections between types of violence across the lifespan. The result is a unique opportunity for new partnerships and collaborations that may facilitate connecting agendas across types of violence, as well as across research, practice, policy, and advocacy (▶ Chap. 2, “Integration of the Types of Interpersonal Violence Across the Lifespan,” by Berman and Hosack). It is important to make these connections to move the field forward; otherwise we remain fixated on, and stuck in, our silos, and territorial disputes will continue to occur. These territorial battles and agendas have kept us from uniting our efforts to make a significant impact on reducing interpersonal violence and abuse across the lifespan. Too often turfism, organizational obstacles, and the marginalization of some voices have hindered collaboration (Giacomazzi & Smithey 2004; Worden 2001). The Handbook is meant to be a current interdisciplinary resource for dealing with these issues, based upon the best research, practices, and advocacy. It begins with an introductory section that addresses some of the issues noted above and also highlights the history of interpersonal violence (▶ Chap. 3, “A History of Interpersonal Violence: Raising Public Concern,” by Pache) and the importance of intersectionality (e.g., ▶ Chap. 7, “Intersectionality,” by Warrier). The Handbook is then divided into parts, but key topics are presented in each. These sections include “Child and Youth Victimization,” “Community Violence and Abuse,” “Intimate Partner Violence and Abuse,” “Adult Sexual Harassment and Assault,” “Adult Survivors of Abuse,” “Older Adult and Elder Abuse,” and “Future Directions in Interpersonal Violence and Abuse.”

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Across parts, chapters emphasize integrating among disciplines and types of violence (e.g., ▶ Chap. 2, “Integration of the Types of Interpersonal Violence Across the Lifespan,” by Berman and Hosack), as well as the importance of system responses to each type of interpersonal violence (e.g., ▶ Chap. 191, “Systems Responses to Older Adult and Elder Abuse,” by Ernst; ▶ Chap. 197, “Future Directions in System Responses to Interpersonal Violence and Abuse: Community Perspectives,” by Sbrocco, McCants, Blankenship, Carter, and DeLeon; ▶ Chap. 73, “The Child Welfare System: Problems, Controversies, and Future Directions,” by Sullivan, Shanahan, Preisler, and Kane). Cross-cutting issues addressed include: definitions, theories, and scope of types of interpersonal violence; systems involved in interventions; intervention approaches and programs; prevention programs; controversial issues; and future directions.

Definitions, Theories, and Scope of Types of Interpersonal Violence Various research approaches are included throughout the Handbook, with a concern across types of interpersonal violence in the importance of establishing uniform definitions; for example, there are chapters dealing with definitions and scope of human trafficking (▶ Chap. 157, “Identifying, Attending, and Protecting US Sex Trafficked Adults and Minors,” by Contreras), the nature of child neglect (▶ Chap. 27, “The Nature of Neglect and Its Consequences,” by Kobulsky and Dubowitz; ▶ Chap. 28, “Child Neglect,” by Passmore, Baxter, and Conway), child sexual abuse (▶ Chap. 30, “Sexual Abuse of Children,” by Conte and Simon), psychological maltreatment of children and youth (▶ Chap. 46, “Psychological Maltreatment of Children and Youth: A Historical Perspective on the Right to Be Emotionally Safe,” by Garbarino), sexual assault (▶ Chap. 148, “The Nature and Scope of Sexual Assault Victimization of Adults,” by Daigle and Azimi; ▶ Chap. 144, “Sexual Assault Perpetration,” by Dean and Swartout), distinguishing parental alienating behaviors from abuse and maltreatment (▶ Chap. 67, “Assessing Causes of Children’s Parent Rejection in Child Custody Cases: Differentiating Parental Alienation from Child Sexual Abuse, Psychological Maltreatment, and Adverse Parenting,” by Milchman), and intimate partner violence in later life (▶ Chap. 185, “Intimate Partner Violence in Later Life,” by Crockett and Brandl). Understanding the distinction between abuse and aggression has become important in both research and practice because too often the terms are used interchangeably which incorrectly influences people’s perceptions and actions (e.g., Geffner 2016). For example, a major issue and controversy in the IPV field has been the question of gender symmetry versus feminist theory about who are the more frequent perpetrators (for a more in-depth discussion of these issues, see ▶ Chap. 90, “Introduction to the Intimate Partner Violence Section: History, Progress, and Lessons Learned,” by Hamberger, Langhinrichsen-Rohling, Rosenbaum, Tinney, and Wagers). Different theories have been proposed over the years to explain the various types of interpersonal violence and abuse. Some of these are discussed in this Handbook,

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including gender-based ones (e.g., ▶ Chap. 95, “Feminist Perspectives of Intimate Partner Violence and Abuse (IPV/A),” by Becker et al.; ▶ Chap. 89, “Sexual and Gender-Based Violence as Warfare,” by Cherepanov) as well as other theories and models (e.g., ▶ Chap. 99, “Intimate Partner Violence Across the Lifespan: Dyadic Theory and Risk and Protective Factors,” by Capaldi, Low, Tiberio, and Shortt; ▶ Chap. 96, “Masculinity and Violence Against Women from a Social-Ecological Perspective: Implications for Prevention,” by Reidy, D’Inverno, Bogen, Swahn, and Jacobs; ▶ Chap. 100, “Clarifying the Complex Roles of Power and Control in Advancing Theories of Intimate Partner Violence,” by Wagers, Sellers, and Hamberger). These debates and discussions are likely to continue in the future. These debates include questions of focus, such as whether interventions should be based on distinguishing causal factors from risk factors; questions of best research methods (such as sample selection; quantitative or qualitative); and conceptual models of intervention (such as mediation versus moderation) (see Koss et al. 2011 for an in-depth discussion).

Systems Involved in Interventions Systems involved in interventions are affected by and respond to interpersonal violence and abuse in multiple ways. For example, there are chapters regarding the mental health system and treatment (e.g., ▶ Chap. 173, “The Contemporary Study of Adult Survivors of Interpersonal Violence and the Development of Mental Health Treatment,” by Courtois and Marotta-Walters; ▶ Chap. 69, “Mental Health and Healthcare System Responses to Adolescent Maltreatment,” by Singer; ▶ Chap. 130, “Mental Health Treatment in the Context of Intimate Partner Violence,” by Warshaw and Zapata-Alma), healthcare system (e.g., ▶ Chap. 129, “The US Mental Health Care System’s Response to Intimate Partner Violence: A Call to Action,” by Langhinrichsen-Rohling, Selwyn, Lathan, and Schneider), criminal and juvenile justice systems (e.g., ▶ Chap. 86, “The Juvenile Justice Response to Violence,” by Butts and Szkola; ▶ Chap. 74, “The Criminal Justice Response to Child and Youth Victimization,” by Cross, Ernberg, and Walsh; ▶ Chap. 121, “A Feminist Perspective on the Criminal Justice System Response to Domestic Violence,” by Harper and Gover; ▶ Chap. 87, “Girls in Juvenile Justice,” by McCarter, Mcleod, Drew, and Granberry; ▶ Chap. 170,“Improving the Police Response to Rape Victims: Persistent Challenges and New Directions,” by Rich), child welfare and other social service systems (e.g., ▶ Chap. 72, “Child Welfare System: Structure, Functions, and Best Practices,” by Cross and Risser; ▶ Chap. 60, “The Experience of Children and Families Involved with the Child Welfare System,” by Murray, Bartlett, and Lent), and school and higher education systems (e.g., ▶ Chap. 166, “Sexual Violence in the Context of Higher Education: The Current State of Research and Policy,” by Bellis; ▶ Chap. 81, “Violence in Schools,” by Cornell and Stohlman; ▶ Chap. 135, “Intimate Partner Violence in College Settings,” by Rodriguez, Beltran, and Chenneville). Specific institutions are also discussed with respect to various types of interpersonal violence and abuse, such as athletic organizations (e.g.,

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▶ Chap. 168, “Sexual Violence in Athletic Organizations,” by McCray and Taylor), residential settings (e.g., ▶ Chap. 38, “Abuse of Youth in Residential Settings/Institutions,” by Canaff), the military (e.g., ▶ Chap. 164, “Military Sexual Trauma,” by Frey-Ho Fung, Larsen, and Gobin), and religious institutions (e.g., ▶ Chap. 165, “Sexual Violence and Religious Institutions: With a Special Focus on the Catholic Church,” by Abrams, Bonagura, and Calkins; ▶ Chap. 59, “Recognizing and Responding to the Spiritual Impact of Child Abuse,” by Vieth and Singer). It is important to study the various systems as part of the overall coordinated response to intervene in interpersonal violence and abuse cases as well as to develop prevention programs. Understanding how the different systems respond is a key aspect of a social ecological approach if we are to be successful in reducing and gradually eliminating these epidemics. It is also clear from the number of different settings, systems of care, and types of abuse that we still have a long way to go to be effective in reducing and eliminating interpersonal violence and abuse across the lifespan.

Intervention Approaches and Programs Intervention is key for reducing the impact of interpersonal violence and abuse. There are different types of interventions for the traumatic effects of victimization that are discussed in the Handbook with respect to children (e.g., ▶ Chap. 70, “The Impact of Neighborhood-Based Interventions on Reducing Child Maltreatment,” by Governale, Nesi, and Garbarino), youth (e.g., ▶ Chap. 82, “Empowerment Strategies and Youth Community Organizing,” by Schwartz, Christensen, and Austin), adults (e.g., ▶ Chap. 119, “System Response to Intimate Partner Violence: Coordinated Community Response,” by Hetzel-Riggin), adult survivors of abuse (e.g., ▶ Chap. 131, “Treatment of Post-traumatic Stress Disorder in Survivors of Intimate Partner Violence,” by Johnson, Zlomick, and Gonzales; ▶ Chap. 182, “The Health Effects of Childhood Abuse and Adversity: Mechanisms, Consequences, and Trauma-Informed Care,” by Kendall-Tackett), non-offending caretakers of abused children (e.g., ▶ Chap. 32, “Succeeding with Nonoffending Caregivers of Sexually Abused Children,” by Vaughan-Eden, LeBlanc, & Dzumaga), and older adults (e.g., ▶ Chap. 193, “Caregiving and Elder Abuse: A Complex Relationship,” by Anetzberger). There are also chapters focusing on intervention for interpersonal violence and abuse offenders of children (e.g., ▶ Chap. 35, “Adult Sex Offenders Against Children: Etiology, Typologies, Investigation, Treatment, Monitoring, and Recidivism,” by Cross, Ernst, Russell, and Jewell-Jensen), of adult sexual assault (e.g., ▶ Chap. 162, “Interventions in the Aftermath of Sexual Violence: Justice, Advocacy, and Treatment,” by Ashton, Hipp, Mandell, and Prichard; ▶ Chap. 163, “Treatment Interventions for Perpetrators of Sexual Violence,” by Lamade and Okanlawon), of adult intimate partners (e.g., ▶ Chap. 140, “Alternative to Violence, a Violence-

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Focused Psychotherapy for Men Using Violence Against Their Female Partner,” by Askeland, Lømo, Råkil, and Isdal; ▶ Chap. 138, “Relationship Violence Perpetrator Intervention Programs: History and Models,” by Murphy, Rosenbaum, and Hamberger), and of older adults (e.g., ▶ Chap. 190, “Perpetrators of Elder Abuse,” by Teaster and Roberto). It is important to note that successful interventions for child and adult victims as well as offenders are necessary to have a significant effect on reducing the incidence and prevalence of interpersonal violence and abuse across the lifespan. By successful, we mean empowering victims to help them heal from the trauma of the victimization to become survivors and then thrivers. By successful interventions for child or adult offenders, we mean changing attitudes, beliefs, and behaviors such that they are no longer at risk for carrying out abusive or assaultive behaviors.

Prevention Programs Prevention is another major topic covered in the Handbook. Ideally, prevention programs should be initiated as soon as possible and as broadly as possible. Child physical abuse prevention is an important part of a comprehensive program (e.g., ▶ Chap. 24, “Child Physical Abuse: A Pathway to Comprehensive Prevention,” by Risser and David), and a program to prevent teen dating violence is also included (e.g., ▶ Chap. 56, “Teen Dating Violence Policy: An Analysis of Teen Dating Violence Prevention Policy and Programming,” by Guillot-Wright, Lu, Torres, MacDonald, and Temple) as well as one concerning sex education (e.g., ▶ Chap. 159, “Reforming Comprehensive Sexuality Education to Prevent Sexual Assault,” by Armistead, Tarantino, Collibee, Ishiekwene, and Cook). Utilizing protection orders for prevention of further intimate partner violence is provided (e.g., ▶ Chap. 123, “Protection Orders: Shielding Intimate Partner Violence Victims from Harm,” by Harper, Gover, and Richards), as is advocacy for the victims/survivors (e.g., ▶ Chap. 120, “Advocacy and Intimate Partner Violence,” by Branco, Keane, Menard, and Ortiz). It is also important that we remember that such programs need to be across the lifespan (e.g., ▶ Chap. 112, “Best Available Evidence for Preventing Intimate Partner Violence Across the Life Span,” by Niolon, Estefan, Kearns, and Dahlberg). It is crucial that we deal with policies in these various areas of interpersonal violence and abuse if we are going to make this a higher priority at community and societal levels, so there are chapters focusing on this topic (e.g., ▶ Chap. 78, “Community Violence Overview: Guiding Principles, Critical Issues, and Prevention and Intervention Strategies,” by Greene and Johnson; ▶ Chap. 171, “Title IX and Restorative Justice as Informal Resolution for Sexual Misconduct,” by Lopez and Koss; ▶ Chap. 88, “Sex and Labor Trafficking: Trauma-Informed Themes Toward a Social Justice Approach,” by Malebranche, Hopper and Corey; ▶ Chap. 75, “The Law and Policy of Child Maltreatment,” by Vandervort).

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Controversial Issues This Handbook does not ignore controversial issues. Several such topics that are timely are discussed. These include dealing with abuse and violence during pandemics and other disasters (see above for the different chapters focusing on this area); the role of firearms and guns in interpersonal violence situations (e.g., ▶ Chap. 9, “Defining Gun Violence Using a Biopsychosocial Framework: A Public Health Approach,” by Kohlbeck, Pederson, and Hargarten; ▶ Chap. 115, “Firearms, Domestic Violence, and Dating Violence: Abusers’ Use of Firearms Violence to Exert Coercive Control and Commit Intimate Partner Homicides,” by Valente and Graber); corporal punishment (e.g., ▶ Chap. 15, “Corporal Punishment: From Ancient History to Global Progress,” by Durrant; ▶ Chap. 23, “Corporal Punishment: Finding Effective Interventions,” by Perrin and Miller-Perrin); commercial sexual exploitation, child torture, and trafficking of children and adults (e.g., ▶ Chap. 157, “Identifying, Attending, and Protecting US Sex Trafficked Adults and Minors,” by Contreras; ▶ Chap. 17, “Domestic Child Torture: Identifying Survivors and Seeking Justice,” by Ratnayake Macy; ▶ Chap. 136, “Human Trafficking and Intimate Partner Violence,” by Reid, Richards, and Kulig; ▶ Chap. 37, “The Commercial Sexual Exploitation of Children,” by Williams, Lim, Trull, and Higgins); and war and conflict (e.g., ▶ Chap. 169, “Wartime Sexual Violence: A Historical Review of the Law, Theory, and Prevention of Sexual Violence in Conflict,” by Wilson). We also included some of the controversies in dealing with child maltreatment, such as Munchausen’s syndrome by proxy (e.g., ▶ Chap. 22, “Munchausen Syndrome by Proxy,” by Alexander and Lashley), abusive head trauma (e.g., ▶ Chap. 16, “Abusive Head Trauma: Understanding Head Injury Maltreatment,” by Brown and Bryant), and the harm and trauma from psychological abuse and exposure to intimate partner violence in the home (e.g., ▶ Chap. 101, “Relation Between Exposure to Parental Intimate Partner Violence During Childhood and Children’s Functioning,” by Fritz and Roy; ▶ Chap. 45, “Psychological Maltreatment of Children: Influence Across Development,” by Hodgdon and Landers). Two other controversial areas are also discussed in various chapters. One is the use of couples counseling for intimate partner violence intervention (▶ Chap. 141, “Couples Counseling to End Intimate Partner Violence,” by Stith and Spencer). It should be noted that although research has indicated that an abusive specific couples approach may be helpful as an alternative in reducing intimate partner violence in certain situations, many states in the United Stated have prohibited such an approach based on ideological grounds rather than on science. This is an area where researchers, practitioners, and advocates have not come to an agreement yet (for a more in-depth discussion of this controversy, see Geffner and Rosenbaum 2001). A more recent issue involves institutional betrayal, especially in cases of adult survivors of child abuse (e.g., ▶ Chap. 177, “Impact of Interpersonal, Family, Cultural, and Institutional Betrayal on Adult Survivors of Abuse,” by AdamsClark, Gomez, Gobin, Noll, and Delker). This has become much more relevant internationally in recent years as many more cases of child abuse, especially child

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sexual abuse, have become known that are based in religious institutions, youth serving organizations, and athletic schools and programs as far back as five decades or more. Research has shown that the trauma is exacerbated when there not only is betrayal trauma by a trusted individual, but then is also covered up, hidden, or denied by the institutions as well. These have led to numerous lawsuits by thousands of individuals globally.

Future Directions In addition to the topics already noted above, the Handbook ends with several chapters dealing with future directions in interpersonal violence and abuse across the lifespan to guide us through the next decade. These include research and prevention (▶ Chap. 202, “The Evolution of Interpersonal Violence Research and Prevention Across the Lifespan in the United States: The Past, Present, and Future,” by Niolon, Treves-Kagan, Dahlberg, and Mercy; ▶ Chap. 201, “Future Directions in Interpersonal Violence Prevention Across the Lifespan,” by Webermann and Murphy), interventions (▶ Chap. 198, “Future Directions in Interpersonal Violence and Abuse Interventions Across the Lifespan,” by Levittan, Yorke, Morrissey, Caprio, and Brownell), advocacy (▶ Chap. 199, “Future Directions in Advocacy in Response to Interpersonal Violence,” by Gill and Nnawulezi), and policies (▶ Chap. 200, “Trauma and Violence Across the Lifespan: Public Policy Advances, Challenges, and Future Directions,” by Elmore-Borbon and Tant). These chapters call for increased attention to the role of victim voices, community-based and culturally appropriate approaches that recognize the developmental aspects of interpersonal violence and abuse. There is also a call for greater coordination and collaboration among the various stakeholders committed to violence prevention, from the grassroots to policy level. Therefore, it is important to include victims/survivors in establishing policies and interventions as stakeholders along with the professionals. The orientation of this Handbook and in the creation of the NPEIV has been to create a partnership among researchers, practitioners, policymakers, advocates, and victims/survivors. The question then arises about how much influence each of the partners should have in decision-making.

Organizing to Connect Agendas: History of the National Partnership to End Interpersonal Violence Across the Lifespan (NPEIV) The NPEIV (www.npeiv.org) grew out of a grassroots desire of professionals across several specialties within psychology to create a venue for greater discussion and collaboration about critical issues regarding interpersonal violence. NPEIV is an organization created to bring groups, agencies, coalitions, organizations, and individuals together for the united purpose of education, training, creating agendas for research, practice, and advocacy, and for building community capacity to implement

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policies. The initial impetus was the 2008 American Psychological Association’s (APA) Summit on Violence and Abuse in Relationships: Connecting Agendas and Forging New Directions, which was co-organized by Jacquelyn White, then president of the APA’s division of the Psychology of Women, and Robert Geffner, then president of APA’s Trauma Psychology division. In total, 17 APA divisions participated as co-sponsors of the first summit as well as various federal agencies, foundations, and other professional organizations. Researchers, practitioners, advocates, and policymakers have called for more opportunities to learn from one another, and the need for collaboration was emphasized, as was the recognition that voices beyond psychology needed to be heard. There was a commitment on the part of many attendees and planning committee members to not let the summit be a one-time event. Feedback from the break-out groups and town hall forum held during the summit resulted in recommendations for next steps that included a desire to see a stronger, more organized commitment to violence-related issues within professional organizations and federal and state agencies. An equally strong desire was expressed to reach beyond disciplinary boundaries to connect to other professions. Other needed voices included public health, social work, medicine and healthcare, law enforcement and the legal profession, education, judiciary, and even business. The need to connect to grassroots organizations and consumers/survivors to foster learning from each other and to create stronger multidisciplinary strategies for the elimination of violence and abuse in relationships also became apparent. As a result, over the next decade annual think tanks were held, the first of which began to map out the future of the fledgling partnership. It was decided that NPEIV would integrate across all aspects of interpersonal violence by building a multidisciplinary partnership focused on linking research, practice, policy, and advocacy. Over the years, NPEIV has continued to grow and establish itself as a collaborative coalition. NPEIV has increased its efforts toward interpersonal violence prevention as well. In addition to an annual forum focused on networking, training, and education, NPEIV has spearheaded the publication of several special issues in leading violence and trauma journals, has participated in federal roundtables and congressional briefings, and has helped establish a national curriculum geared toward interpersonal violence prevention. Today, NPEIV continues its dedication to interpersonal violence prevention primarily through Action Teams focused on public policy and engagement, training and mentoring, practice, research and dissemination, and global peace. This Handbook is the latest project, following on the 2016 release of the National Plan to End Interpersonal Violence Across the Lifespan (discussed below). The NPEIV summits bring together researchers, practitioners, policymakers, advocates, and survivors across disciplines and fields to find a way to reconcile some of the inconsistent and conflicting theories, findings, and interpretations to make real headway in reducing levels of violence and victimization. The expertise and experiences of the various voices, combined with a willingness to admit to uncertainty about knowledge from other perspectives and stakeholder positions, have served as the catalyst for getting very focused on determining how scientifically derived knowledge can best drive various service and policy efforts. What has

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Table 1 Major issues and cross-cutting themes • Focusing on the theory behind multiple types of violence, perhaps by way of generating testable hypotheses, including exploration of how levels of oppression, colonial thought processes, and other broader systems affect how we think about the causes and effects of violence • Focusing on creating an interdisciplinary research agenda that utilizes what we know • Taking a developmental perspective on violence across the lifespan intergenerationally • Focusing on assessment issues and measures in each of the areas • Focusing on curriculum development, both in the classroom and in continuing education programs, that addresses training issues in all professions that have relevance to interpersonal violence and abuse • Inviting experts from countries where violence rates are low • Developing a marketing campaign to affect public perceptions • Including community members and consumers in the discussion

emerged is a blueprint for the elimination of violence and abuse interpersonally by using science to help better understand the causes of violence. In addition, there has been a focus on best practices for intervention and prevention, fostering collaborations with various professional, grassroots, and other advocacy organizations and developing campaigns to educate the public and policymakers about interpersonal violence and abuse. Additionally, the annual summits have led to the identification of major issues and cross-cutting themes in changing national and international priorities to end interpersonal violence and abuse (see Table 1). Interpersonal violence should be seen as a public health crisis involving social justice issues. It is time to create an environment from a societal standpoint that reduces the amount of victim blaming and shame that hinders the healing process. Furthermore, we need to direct more attention to systemic and historical trauma, the intergenerational transmission of violence, racism, misogyny, oppression, and the abuse of power that affects disenfranchised and marginalized people the most. Many of these issues surfaced again with the COVID 19 pandemic as well as with the exposure of racial injustices and health disparities throughout the world.

Action: Call for Integrating Research, Practice, Advocacy, and Policy Throughout this chapter, we have emphasized the importance of finding commonality across types of violence, and we have identified various lenses, when considered in conjunction with each other, that support a more unified integrated approach. In this section, we turn our attention to another form of integration, one that calls for various sectors (researchers, practitioners, advocates, and policymakers, including those in the fields of psychology, public health, healthcare, law enforcement, law, education, etc.) to form alliances to enhance the goal of reducing interpersonal violence and abuse across the lifespan. Figure 5 is a visual representation of where such alliances could lead.

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Fig. 5 New perspectives on integrating research, practice, advocacy, and policy: Connecting agendas

This figure challenges us to commit to more interactions across sectors to learn from each other in order to mutually support goals so that we can actually influence public policies and change national and international priorities. The result would be policy-/advocacy-informed research; research-informed policy/advocacy; policy/ advocacy-informed practice; practice informed policy/advocacy; practice-informed research; and research-informed practice. A key goal is advocacy for policy recommendations for interventions and prevention programs that are informed by sound research findings as well as the real-world implications of implementing and scaling up treatment, intervention, and prevention programs. Such policies would then seamlessly take intersectionality into account, moving the field beyond the sort of piecemeal approach to prevention that happens all too often. Indeed, many examples of just such partnerships have emerged. Meta-integration would result when all stakeholders form a collaboration in which systemic practices reflect the input of researchers, practitioners, advocates, and policymakers in a synergistic process of interactions and feedback, each learning from the other and adapting accordingly. Although as a society we are not there yet, several examples of efforts moving in this direction are noteworthy. For example, the Office of Violence Against Women in the United States requires grantees’ participation in a coordinated community response (CCR; cross-disciplinary partnerships between various stakeholders) to violence against women. Over the past four decades, collaborations between women’s centers and criminal justice agencies have come together to develop strategies to stop the violence and protect victims/survivors. Initially the focus was on reforms in the criminal justice/legal system, including examination of the policies, procedures, and rules that guided the practice of law enforcement officers, prosecutors, judges, and court personnel. This effort resulted in modified policies and practice. Training in new protocols and systems then occurred. More

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recently, CCRs have expanded beyond criminal justice reforms and offer a useful model for cross-disciplinary collaboration and public accountability (OVW 2012, Report to Congress). Research has documented the value of including agencies other than criminal justice (Ingram et al. 2010; Stewart 2013). See also White et al. (2019) for examples of building partnerships that address the needs of victims and perpetrators that are inclusive of victim voices. This has become even more relevant with the recent protests and the Black Lives Matter movement discussed above to promote racial justice and accountability. Several examples of policy-informed research have been reported by Child Trend (Jordan and Cooper 2016). They provide numerous examples of how academic research has been used by policymakers. They identified four ways for sharing research with policymakers, including interpreting complex research concepts, sharing research during crises, using data to highlight and address inequity, and strengthening and applying the evidence base in decision-making. For example, McKlindon (2019) described how research and evaluation-informed provisions of the Family First Prevention Services Act in the United States led to the prioritization of familybased placements when children enter foster care. The CDC’s Connecting the Dots approach (Wilkins et al. 2014), mentioned at the beginning of this chapter, provides yet another example of a cross-cutting perspective that encourages evidence-based interventions, programs, and policies through partnerships that facilitate dissemination and implementation of the research. This perspective necessitates networks and collaboration of stakeholders in diverse fields. Globally, we see increased calls for cross-sector collaborations. For example, the World Health Organization’s (WHO) report on violence and health notes that for successful implementation of violence prevention programs to succeed, there must be alliances and political commitment (World Health, 2002). These should include collaboration and exchange of information, as well as integration of violence prevention into social and educational policies in ways that promote social equality and social justice. Examples of projects that the NPEIV members are currently working on concerning best practices, a violence research digest, setting up a model network for trauma-informed providers of mental health, and various policy statements can be seen on their website (https://www.npeiv.org/). The NPEIV also holds a think tank at the end of each summer that welcomes participants from all sectors in order to expand the network.

National Plan to Reduce Interpersonal Violence and Abuse Across the Lifespan In 2016, a comprehensive national plan was developed by NPEIV members to reduce and eventually end interpersonal violence and abuse across the lifespan within 2–3 generations (https://www.npeiv.org/national-plan). This plan offers another cutting-edge example of collaboration across sectors that focuses on education and training of the next generation of researchers, service providers, policymakers, and advocates, with a parallel focus on impacting systemic policy

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and practices. The National Plan includes 22 specific recommendations that encompass practical ways to change practices, enhance research, implement policies, and improve advocacy in order to reduce and then end such violence and abuse. This plan is described in more detail in this Handbook (▶ Chap. 11, “A National Plan to End Interpersonal Violence Across the Lifespan,” by Berman and Vieth). It is hoped that individuals, agencies, organizations, and coalitions throughout the United States and other countries review these recommendations and the details underlying them in order to change priorities globally by working together so that change can begin in an earnest manner.

Key Points • All types of violence require a base of knowledge to inform our work, and we must recognize and act on the interrelatedness of all forms of violence. • We must strive to identify the gaps, as well as common connections, in knowledge among our fields and specialties. • It is important to view interpersonal violence and abuse from a social-ecological framework that emphasize intersectionality. • We must break down silos of thinking among those focusing on differing forms of violence (such as child maltreatment, teen dating violence, sexual assault, intimate partner violence, elder maltreatment, community violence, and the like). • We need to identify barriers to responsiveness for target groups and consumers. • We need to develop an action agenda for differing target groups affected by interpersonal violence and abuse. • Collaboration and integration of thinking must become national and international priorities. • The public and grassroots organizations, including victims/survivors, must be viewed as partners in knowledge building and change. • We need to listen to our colleagues across all disciplines, as well as victims/ survivors, in this effort, and to develop interdisciplinary team approaches to better understand and reduce violence and abuse. • And finally, we must strive to find common ground and jargon-free messages to create a movement to reduce interpersonal violence and abuse.

Summary and Conclusion Historical approaches to interpersonal violence have been siloed or fragmented by types of violence (child maltreatment and abuse, intimate partner violence, sexual assault, youth violence, community violence, abuse of older adults), by forms of abuse (psychological, sexual, physical), by developmental stage (childhood, adolescence, adulthood, older adulthood), by context (home, work, school, military, community, country), and by focus of interest (research, practice, advocacy, policy). It has also been siloed by theoretical framework and discipline (mental health,

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healthcare, criminal justice, judiciary, education, social service, public health). Breaking out of the silos and exploring interpersonal violence from multidisciplinary and interdisciplinary perspectives can help in the identification of commonalities across types of violence and identify various lenses that support a more unified approach. This will necessitate networks and collaboration of stakeholders from diverse fields. By bringing together multiple stakeholders and engaging in mutually supportive agenda-building activities, using a cross-cutting perspective, the needs of victims, perpetrators, their families, and communities will be better served as evidence-based interventions, programs, and policies are developed and implemented. This perspective necessitates networking and collaboration of stakeholders in diverse fields. Such collaborative approaches will require flexibility and radical listening to each other, including victims, perpetrators, and their families (Koss et al. 2017).

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analyses, and emergent priorities. Volume II: Navigating solutions (pp. 261–305). Washington, DC: American Psychological Association. Koss, M. P., White, J. W., & Lopez, E. (2017). Victim voice in re-envisioning responses to sexual and physical violence nationally and internationally. American Psychologist, 72(9), 1019–1030. https://doi.org/10.1037/amp0000233. Lopez Levers, L. (Ed.). (2012). Trauma counseling: Theories and interventions. New York: Springer Publishing Company. https://doi.org/10.1891/9780826106841. McKlindon, A. (2019). Applying the research and evaluation provisions of the Family First Prevention Services Act. Retrieved from Applying the Research and Evaluation Provisions of the Family First Prevention Services Act. https://www.childtrends.org/publications/applyingthe-research-and-evaluation-provisions-of-the-family-first-prevention-services-act Office on Violence Against Women (OVW). (2012). 2012 biennial report to Congress on the effectiveness of grant programs under the Violence against Women Act. Retrieved from https:// www.justice.gov/sites/default/files/ovw/legacy/2014/03/13/2012-biennial-report-tocongress.pdf Perry, B. (2001). The neuroarcheology of childhood maltreatment: The neurodevelopment costs of adverse childhood events. In K. Franey, R. Geffner, & R. Falconer (Eds.), The cost of child maltreatment: Who pays? We all do (pp. 15–37). San Diego: The Family Violence & Sexual Assault Institute. Putnam, K. T., Harris, W. H., & Putnam, F. W. (2013). Synergistic childhood adversities and complex adult psychopathology. Journal of Traumatic Stress, 26, 435–442. Repetti, R., Taylor, S., & Seeman, T. (2002). Risky families: Family social environments and the mental and physical health of offspring. Psychological Bulletin, 128(2), 330–366. https://doi. org/10.1037/0033-2909.128.2.330. Rosenbaum, A., Geffner, R., & Benjamin, S. (1997). A biopsychosocial model for understanding relationship aggression. Journal of Aggression, Maltreatment, & Trauma, 1, 57–79. Stewart, M. (2013). Cross-system collaboration. Los Angeles/Durham: National Center for Child Traumatic Stress Network. https://www.njjn.org/uploads/digital-library/NCTSN_Cross-systemcollaboration_Macon-Stewart_September-2013.pdf Wegner, R., & Abbey, A. (2016). Individual differences in men’s misperception of women’s sexual intent: Application and extension of the confluence model. Personality and Individual Differences, 94, 16–20. https://doi.org/10.1016/j.paid.2015.12.027. White, J. W., & Kowalski, R. M. (1998). Male violence against women: An integrative perspective. In R. G. Geen & E. Donnerstein (Eds.), Perspectives on human aggression (pp. 205–229). New York: Academic. White, J. W., Koss, M. P., & Kazdin, A. E. (2011). Conclusions and next steps. In J. W. White, M. P. Koss, & A. E. Kazdin (Eds.), Violence against women and children: Consensus, critical analyses, and emergent priorities. Volume 1: Mapping the terrain (pp. 287–310). Washington, DC: American Psychological Association. White, J. W., Sienkiewicz, H., & Smith, P. H. (2019). Envisioning future directions: Conversations with leaders in domestic and sexual assault advocacy, policy, service, and research. Violence Against Women, 25(1), 105–127. https://doi.org/10.1177/1077801218815771. Wilkins, N., Tsao, B., Hertz, M., Davis, R., & Klevens, J. (2014). Connecting the dots: An overview of the links among multiple forms of violence. Atlanta/Oakland: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention/Prevention Institute. Worden, A. (2001). Models of community coordination in partner violence cases: A multi-site comparative analysis. Final report for National Institute of Justice, grant number 95-WT-NX0006. Washington, DC: U.S. Department of Justice, National Institute of Justice, NCJ 187351. http://www.ncjrs.gov/App/Publications/abstract.aspx?ID¼187351 World report on violence and health: Summary. (2002). Geneva: World Health Organization. https://www.who.int/violence_injury_prevention/violence/world_report/en/summary_en.pdf

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Integration of the Types of Interpersonal Violence Across the Lifespan Pearl S. Berman and Alexandra G. Hosack

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Historical Reductionism: Splitting Apart the Complex Context of Violence . . . . . . . . . . . . . . . . . . . Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ability Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Racial and Ethnic Identities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sexual Orientation and Gender Identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Violence by Environment and Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community and SES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Institutions: Schools, Military, and Prisons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Border Crossings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A New Vision: Interconnections, Not Silos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Lifespan Context of Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cascading Impact of Early Violence and Impact Across the Lifespan: Focus on Attachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Attachments in Infancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Attachments in Early Childhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Attachments in Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Attachments in Adulthood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Attachment in Older Adulthood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lifespan Versus Incident Approach to Understanding Violence Exposure . . . . . . . . . . . . . . . . . . . . . Public Health Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Multidisciplinary Responses to Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. P. S. Berman (*) · A. G. Hosack Indiana University of Pennsylvania, Indiana, PA, USA e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_304

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Shift in the Role of Criminal Justice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shift in the Role of Educators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shift in the Role of Medical Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shift in the Role of Social Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shift in the Role of Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shift in the Role of Policy Makers/Politicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Whether at home, in school, in the community, at work, in public offices, or in the courts, people have the human right to be safe (NPEIV, National Plan to End Interpersonal Violence (NPEIV), National partnership to end interpersonal violence across the lifespan. In Global partners for peace. Retrieved from https://2c84ec75-db94-4a90-b4cc-a899fc583574.filesusr.com/ugd/8636ad_704 f6d5d83d14ab586ae8a7f713588a1.pdf, 2017). Exposure to any form of interpersonal violence is antithetical to this right. Professionals developed many strategies to end interpersonal violence. However, violence occurs within a complex context and, historically, professionals pulled apart this complexity to look for unique factors in different forms of violence. This unintentionally isolated professionals, victims, and perpetrators into silos by type of violence, age of victim, place of incident, and professional training. This chapter will discuss a more integrated response to violence research, prevention, intervention, and advocacy that draws from the commonalities found across diverse forms of IPV in risk and preventative factors. Conclusions will be drawn for taking a lifespan perspective versus incident approach to cases, using multidisciplinary teams to comprehensively address violence using evidence-based practices. Violence is a public health crisis and ending it will require shifts in how criminal justice, social service, and other professionals carry through their responsibilities. In addition, their training prior to entering the job force needs to include skill-based learning and how to provide trauma-informed care. Local, state, and national leaders need to shift their view of violence from something to isolate through incarceration to a public health risk that requires equal access to important sources of resiliency, such as quality education, health care, and affordable housing for the entire US population (NPEIV, National Plan to End Interpersonal Violence (NPEIV), National partnership to end interpersonal violence across the lifespan. In Global partners for peace. Retrieved from https://2c84ec75-db94-4a90-b4cc-a899fc583574.filesusr. com/ugd/8636ad_704f6d5d83d14ab586ae8a7f713588a1.pdf, 2017). Keywords

Public health · Lifespan · Violence prevention · Perpetration · Multidisciplinary · Polyvictimization

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Introduction Case Study Jasmine Irwin, only 4 pounds and 3 ounces at birth, lost her life at 2 years old as a result of a brutal physical attack from her mother. This assault took place in front of her 4-year-old brother. Jasmine’s family lived in a deteriorating neighborhood. Both parents, her mother Tami and father Jasper, were involved with drugs and had a history of domestic violence. In fact, Tami may have been taking drugs by Jasper while pregnant with Jasmine. Despite this history, the hospital released Tami and Jasmine without drug testing to determine if Jasmine had been affected by methamphetamine in the womb. No support services were provided to the mother and child. Ten months later, Tami entered drug rehabilitation and indicated on medical forms that she was struggling with parenting and experiencing severe anxiety; she received no parenting or mental health support. The case of Jasmine’s family is all too common, with multiple indicators of violence yet little in the way of a comprehensive assessment or provision of services that could have put the family on a different, more positive trajectory. Current research finds that Jasmine’s story reflects common elements found in many other cases. Interpersonal violence (IPV) is often a family affair involving more than one perpetrator, victim, and bystander, to specific episodes of violence (Hamby and Grych 2013). This chapter will refer to this case as it explores the complex interconnections between IPV across the lifespan. IPV can begin as early as pregnancy, when, for example, a violent partner kicks a pregnant woman in the stomach. Jasmine Irwin was born to such a family (Palmer and Huseman 2019). There are warning signs that can lead to early identification of at-risk families. Multiple risk factors, including living in the type of deteriorating neighborhood Tami and Jasper lived in, have been found related to poor child adjustment (Miller-Graff et al. 2018). Although there are no further facts available about Tami and Jasper, evidence would suggest that their history of abusing substances likely increased their risk for impulsive, abusive, and neglectful (Freisthler et al. 2017) behavior, thereby putting their children at risk. If their misuse of alcohol and drugs had started in the early school years, they would have been at increased risk for dating violence (Parker et al. 2016a), which has been found to start as early as the sixth grade (Orpinas et al. 2017) and is often associated with sexual assault (Vagi et al. 2015) and poor school achievement. A more thorough examination of Tami and Jasper’s lives might have indicated many choice points where interventions from the school, social services, or the judicial system might have changed their life trajectory in a less traumatic direction. It is likely that Tami and Jasper were born into troubled families, increasing the risk of their developing insecure attachments to their own unprepared parents, thus beginning the intragenerational transmission of violence (Bonache et al. 2017). Starting in elementary school, peer relationships become increasingly important. Tami and Jasper might have begun early use of substances after seeing this behavior modeled at home to numb feelings

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of isolation, rejection, or anger. Their desire to form attachments, paired with poor attachment skills, would make it more likely they would develop deviant peer relationships (Foshee et al. 2016). This could have further reinforced drug use, continued early sexual experiences, and decreased school achievement. If their parents modeled violent behavior, they might have become involved with physical and sexual violence in their early teen years. Intervention by a teacher or school counselor might have introduced adolescent Tami to the free training program, Dating Matters, developed by the Centers for Disease Control and Prevention (CDC) (https://vetoviolence.cdc.gov/apps/datingmatters/). This training could have taught her the difference between a healthy and an abusive dating relationship. As a result, Tami might have avoided abusive relationships, including a relationship with Jasper. These early interventions did not happen. Jasmine’s tragedy might still have been prevented if, during Tami’s pregnancies, a medical professional recognized her as a young mother in need of support. She could have been provided an evidence-based intervention such as the Nurse-Family Partnership. This program could have sent a nurse to Tami’s home and provided her with help in planning a healthy pregnancy. After birth, the nurse could continue to come to the home for 2 years to support healthy child development (Olds et al. 2019). As her first child became a preschooler, he could have become involved in Early Head Start and then in Head Start. This would have helped Tami’s son, and later Jasmine, become set on the road for school success. If Tami had experienced adequate parenting, was satisfied in her relationship with Jasper, and felt her neighborhood was supportive, her daughter Jasmine’s life might have proceeded with less risk, despite poverty and substance abuse (Miller-Graff et al. 2018). However, Tami’s social ecology of maternal victimization and living in a deteriorating neighborhood heightened her risk for depression and poor outcomes for her children. Professionals have not quietly read about tragedies like Jasmine’s in the news. They have engaged in decades of hard work trying to end the intergenerational transmission of violence. This chapter provides a brief history of their efforts, which although including research, intervention, and prevention approaches, have been siloed by age, ability status, gender, racial and ethnic affiliation, socioeconomic status, and so forth. These efforts increased awareness of the many different types of IPV and the movements spawned to end each of them. However, these efforts differentiated each type from the others, leaving the critical commonalities in the background and not considered central to understanding each type of violence. Preventing the intergenerational transmission of violence requires a shift where the commonalities are put into the foreground of research, prevention, and intervention. This new approach includes a focus on common risk and protective factors across the lifespan. This chapter will use a lifespan framework for understanding these common factors across multiple forms of IPV. These factors begin within interpersonal relations rooted in the dynamics of insecure attachments, the use of hypermasculine behavior, and intentional social isolation. These interpersonal relationships are embedded within social and political factors supportive of gender

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inequality, income inequality, and inequitable access to quality education and medical and psychological services. This approach underscores the complex context that supports IPV. After discussing how current research focuses on common risk and protective factors in development, a public health approach for taking a proactive social and personal response to ending violence is introduced. Professionals need to shift their traditional roles of working within their professions to working across their professions as collaborative multidisciplinary teams (MDTs). Fully implementing the National Plan to End Interpersonal Violence in Three Generations (National Partnership to End Interpersonal Violence [NPEIV] 2017) would support shifts in the current violence response and prevention systems that are needed to comprehensively address the public health risks of interpersonal violence. Professionals need to transform the national conversation from cries of “do something” after events like Jasmine’s death, a school shooting, or community deaths to the proactive demand to fully fund evidence-based practices that can end violence.

Historical Reductionism: Splitting Apart the Complex Context of Violence C. Henry Kempe made child abuse visible to society in 1962 when The Battered Child Syndrome was published (Kempe et al. 1962). Since that time, the visibility of many forms of IPV has increased, as has the recognition for trauma-informed care across all forms. Unfortunately, each type of violence was studied within a variety of silos to break down the problem of violence into smaller, more manageable slices and then eradicate each slice. Silos are the isolated areas in which groups work but fail to collaborate and communicate across, even when working toward a similar broad goal. Multiple silos exist, complicating further the goals of research or practice or advocacy, or on theoretical emphases such as gender and patriarchy (White 2009), power and control (Hawley and Bower 2018), or attachment (Bonache et al. 2017). Silos have also developed around the level of communication and collaboration. They have developed around type of violence, such as psychological, physical, and sexual; by age, such as child abuse, teen dating violence, and elder abuse, which usually includes focus on specific relationships, such as parent-child or spousal; and by environment/context of the violence, such as home, school, or workplace. More silos have appeared given the recent attention focused on specific attributes of victims, such as gender, ethnicity and/or race, ability status, and sexual orientation and gender identity. Fragmentation also has resulted from exclusive focus on victims or on perpetrators and on level of analysis used including individual, relational, or ecological (Cambell et al. 2009). It is beyond the scope of the present chapter to address each of these types of silos; other chapters in the handbook address them more fully. However, silos based on age and attributes of victims are briefly discussed, followed by a brief overview of various environments that have been the focus of scrutiny. Although critical of silos and the shortcomings created by the fragmentation, we recognize the enormous contributions each has made to

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advancing knowledge about each type of IPV and that in many ways the more focused work has led us to the point where a more comprehensive and collaborative approach became visible as the way forward.

Age Siloed approaches to IPV have developed around the age of the victim. The high levels of victimization documented at each age level have raised awareness of the need to act, but in addressing IPV at each age level, separate research, treatment specialties, and prevention programs have developed. The age-based approach fails to recognize fully the complex context of violence. The seeds of these many forms of violence lie in interpersonal factors such as child abuse and neglect, disrupted attachments, and emotional dysregulation. Although occurring at different ages, child physical abuse, teen dating violence, and IPV can all involve similar dynamics such as feelings of emotional betrayal and a lack of non-violent conflict-resolving strategies, social factors such as patriarchy and gender-role stereotypes that support unequal power and coercive control in society as well as in homes (Elizabeth 2015), as well as ecological factors such as poverty leading to exposure to community violence (Cambell et al. 2009).

Ability Status The focus on people with disabilities has created another silo. People with various kinds of disability, whether cognitive or physical, are at double the lifetime risk of victimization (Hahn et al. 2014). Older adults who become disabled may put increased strain on a relationship, leading to physical or emotional abuse (Acierno et al. 2010). Women with disabilities experience higher rates of IPV, sexual assaults, and emotional abuse than other women. Their increased vulnerability may be due to many factors, including communication barriers hampering their ability to report effectively, social stigma, and discrimination. Individuals with mental illnesses may have the highest risk (Hahn et al. 2014). Children with special needs that place additional responsibilities on caretakers are also at an increased risk (CDC, Division of Violence Prevention [DVP] 2019a). When the perpetrator is a “trusted” other, victims may not know where or to whom to go to report abuse (Breiding and Armour 2015). Whether a young child or an adult with dementia, abuse is most likely to be at the hands of someone they know, and if they are an adult, it is most likely an intimate partner using the same power and control dynamics found in early age periods. However, they may also be abused by a caretaker or personal assistant. Adults with cognitive disabilities and older adults who may have always had or who developed cognitive disabilities have higher rates of sexual assault. Older adults with disabilities may struggle to set appropriate boundaries around their caretaking needs; this is particularly an issue if they need toileting and bathing support. Those with cognitive impairments are also at increased risk of financial exploitation (Breiding and Armour 2015). This may lead them to view the

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incursions on their autonomy to be their own fault, through a lack of communication, rather than power and control being exerted over them by a perpetrator who targeted them due to their vulnerabilities (Elizabeth 2015).

Gender People of all genders are victimized. However, those who identify as women, transgendered, or gender nonconforming are at greater risk. As a result, genderspecific approaches to IPV have been developed, perhaps exemplified most visibly through the Violence Against Women Act in the USA (Rosenthal 2017). Patriarchal countries, which support the development of hypermasculine stereotypes, serve as ecological risk factors for the perpetration of physical and sexual violence around the world (CDC, DVP 2019b; Elizabeth 2015; WHO 2013). Unequal hierarchies of power and finances between men and women, entrenched within the institutions of society by gender norms, and social constructions of masculinity fuel male-female violence, including intimate partner violence, murder, assault, and rape (Fleming et al. 2015; White and Kowalski 1998). Globally, women average engaging in three times more unpaid labor in support of families than men. This unpaid work is considered one of the reasons women have increased health risks, due to not getting adequate sleep or time for self-care (Ferrant and Thim 2019). Women’s health around the world is also poorer than that of men (WHO 2015). Interventions that are gender-transformative and equalize the power between partners in relationships and within society can reduce violence (Fleming et al. 2015).

Racial and Ethnic Identities Individuals from all racial and ethnic groups are victimized by violence, but lifetime victimization for many forms of violence is highest among multi-racial women (57%), American Indian/Alaska Native women, (48%), non-Hispanic Black women (45%), non-Hispanic Black men (37%), and non-Hispanic White men (30%) (Smith et al. 2017). However, historically much research has focused on Whites, with the result being fewer resources directed toward other racial and ethnic groups. Thus, the recent increased focus on these other groups has provided a needed remedy, including a call to better understand possible unique risk and protective factors, including racial slurs and discrimination which are emotionally abusive and increase negative psychological and physical outcomes within inner city populations (Cronholm et al. 2015). Historical trauma experienced by various racial and ethnic groups, reinforced by news events experienced in person or through media, is abusive or dismissive of recent acts of violence against people of color (Carter et al. 2017). The power and control that the majority White culture has, to develop the narrative around these incidents of violence, is an ecological variable that serves to reinforce this historical trauma and expand it to include new types of abuse (Cambell et al. 2009).

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Sexual Orientation and Gender Identity Recent focus on LGBTQIA+ populations reveal that they are at higher risk for violence across the lifespan than heterosexual and cisgendered persons. Additionally, the recent focus on these populations suggests multiple ways that social and political forces reinforce their inequality relative to heterosexual and cisgendered populations. The rates for bisexual people (37% in males, 61% in females) and those who identify as gay and lesbian (26% in males, 44% in females) in comparison to heterosexuals (29% in male; 35% in females) (Smith et al. 2017). Same-sex couples experience intimate partner violence at higher rates than heterosexual couples; the same power and control dynamics have been found suggesting that differential power is key to the dynamics of intimate partner violence (Smith et al. 2017). Within sexual and gender minority youth assigned female at birth, a high proportion experience some form of IPV, and this rate is even higher for ethnic minorities within this group (Whitton et al. 2019). The mistreatment that youth who identify with sexual minority groups face in schools makes them at increased risk for many negative events including increased harassment and violence; this can result in low self-esteem and self-injurious behavior. Gay and bisexual males are at increased risk of HIV infection. Those from minority racial backgrounds and poorer socioeconomic classes are at even increased risk (APA, Public Interest Directorate 2011). Lifetime IPV ratings for transgender and gender nonconforming youth are 45%, and those youth who participate in sex work, and are ever incarcerated, or who experience depressive symptoms are more likely to report IPV and more likely to be involved in violence due to living in disadvantaged neighborhoods, targets of socially sanctioned hate (Cambell et al. 2009; Goldenberg et al. 2018).

Violence by Environment and Context In addition to siloing IVP by age, identity, or demographic attributes of victims and perpetrators, siloing has also occurred by environments and contexts within which the violence occurs, including family, school, community, workplace, military, prisons, sports camps, faith-based institutions, or the border. If one sibling assaults another, a parent is likely to be the arbiter of how this assault is handled. When it is parent-child abuse, child protective services may become involved. Violence within schools is typically handled by the principal and vice principal. Violence in the community, if reported, is directed to the police. Violence against older adults, if reported, goes to adult protective services. As a result, different people with different levels of training are “in charge” of how violence is responded to and different legal and moral mandates are also invoked. This leads to great inconsistencies in the responses to violence. It is beyond the scope of this chapter to delve into the study of IPV with each of these environments or contexts but a few examples are offered.

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Community and SES People can be exposed to violence in their communities through hearing about, witnessing, or directly participating in violence and violence impacts people at all socioeconomic status levels, as well as rural or urban locations. However, poor individuals, especially when living in low socioeconomic status neighborhoods, are at increased risk. Living in poverty can involve a complex context of disadvantage that includes food insecurity, inadequate housing, living in a higher-crime neighborhood, and attending poorer-quality schools. The poor in inner cities are exposed to adverse childhood experiences such as child abuse and neglect, and those from minority groups face acts of racism and discrimination that are additional sources of adversity (Cronholm et al. 2015). Neighborhood deterioration is more highly related to violence than poverty, and these neighborhoods may show a lack of trust between residents and the police (Robinette et al. 2018). Furthermore, the widespread exposure of youth to community violence is now viewed as a critical issue. While the poor experience more victimization, data also indicate that, as financial stability improves, exposure to IPV may reduce, emphasizing the ecological influence of poverty on violence. Recognizing there are ecological variables that increase risk for exposure or involvement in violence is critical to reduce social victim-blaming and internalized self-blame of victims (Cambell et al. 2009).

Institutions: Schools, Military, and Prisons Schools Schools are environments where people experience bullying, harassment, sexual assault, rape, and school shootings. Violence is negatively associated with resilience (Howell et al. 2018). Students can fear coming to school and despair while there. Yet, success in school and school completion is also positively associated with resilience (Howell et al. 2018). An emotionally supportive school environment with clear rules and expectations and teachers who provide scaffolding to support learning can be positive environments for students. Students can turn to teachers for support and are less likely to then experience school failure and dating violence (Cornell and Bradshaw 2015). This underscores the importance of understanding institutional practices that can increase as well as decrease the risk of violence (Cambell et al. 2009). Military Similar to educational settings, the military is an institution with practices that can exacerbate IPV or ameliorate it. The armed services train and deploy to serve and protect the citizens and government of the USA. However, military personnel are not always safe from their superiors and colleagues. An estimated 26% of active females in the US military report violence from an intimate partner over the course of a year (Gierisch et al. 2013). According to the 2017 Military Family Lifestyle Survey, 15%

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of military and veteran family members report not feeling safe. Of these family members, 87% do not report their physical abuse (Akin 2018). The National Defense Research Institute (NDRI 2014) reports that 20,000 active duty personnel are victims of unwanted sexual contact. The Department of Defense methods for reporting and responding to cases between military personnel include the Sexual Assault Prevention and Response (SAPR) programs and the Uniform Code of Military Justice (UCMJ) (Stander and Thomsen 2016). The military structure can both support and discourage continued victimization and perpetration through its hierarchy, which allows opportunities to abuse power but also provides opportunities to act. In addition, it can support coverups of victimization and perpetration through its encouragement of cohesion, while it can also use this same value to encourage bystanders to take effective action to prevent assaults (Stander and Thomsen 2016). The social ecology of the military may serve to reinforce stereotypes that “might” makes “right” that can support IPV. The predominance of males in positions of authority in the military may reinforce stereotypes that men have the “right” to dominate women (Cambell et al. 2009; White and Smith 2009).

Prisons Prisons constitute another set of institutional practices that can have a profound effect on IPV. Prisons are intended to protect society by housing and isolating dangerous individuals. However, the prison environment too often normalizes power and control dynamics, coercive control, and violence (Elizabeth 2015). Institutional betrayal has also led to bias in the judicial system that leads to people of color and the poor being incarcerated and losing their civil rights while Whites who commit equal crimes remain in the community (Bronson and Carson 2019). Inmates are not always safe in prison, and this can initiate or reinforce violent tendencies or behaviors. During 2015, there were 24,661 allegations of sexual victimization in prisons, with 58% alleged at the hands of prison staff and 42% from other prisoners (Rantala 2018).

Border Crossings Border crossings represent a relatively new environment for an examination of IPV, including child abuse and rape. Populations may cross borders seeking economic advantage; however, many current migrants are trying to find safety. There are an estimated 70 million people who flee their homes to escape violence. Doctors Without Borders estimates 500,000 people flee extreme violence in the Northern Triangle (El Salvador, Guatemala, and Honduras) alone, with many coming to the border between Mexico and the USA (Lawrence 2018). Individuals crossing the border from Mexico into the USA often experience further acts of violence, including beatings, sexual assault, and kidnapping as they try to gain safety (Valencia 2017). In 2019, a surge of apprehensions and detainments of unaccompanied children occurred at the border crossing from Mexico into the USA (US Customs and Border Protection 2019). Though initiatives to increase safety at border

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crossings exist, migrant deaths and border violence continue to be a public health crisis. The lack of power that undocumented and new immigrants experience in society makes them more vulnerable to violence due to political factors outside their control, such as social myths that they are dangerous to society (Cambell et al. 2009).

A New Vision: Interconnections, Not Silos The dedicated professionals within each of these silos have worked hard to recognize and intervene in cases of IPV. Independent movements with calls to focus on ending the violence have emerged. For example, the Zero to Three Movement (www. zerotothree.org) focuses on efforts to build resilient development and healthy relationships between parents and their children in early childhood. The Zero Abuse Project (https://www.zeroabuseproject.org/) seeks legal redress for victims of sexual assault and abuse. Futures Without Violence strives to prevent violence against women and children around the world (https://www.futureswithoutviolence.org). Showing Up for Racial Justice (https://www.showingupforracialjustice.org) seeks to create a community of inclusion and justice in which all people desire to participate. Due to these movements, and many others, awareness of the existence of different forms of IPV has increased, and strategies for helping victims recover continue to proliferate. However, the complex context of IPV remains in the background, often embedded in many systems of society. Research indicates that all forms of violence may cause similar short-term as well as long-term substantial and traumatic impact. It is the “quantity” of violence exposure and the protective or promotive factors within the environment, not necessarily the type or context of violence, that is most consequential (Howell et al. 2018). While there may be unique features of different types of violence that involve important risks that aren’t present in other types of violence, it may be that the definitions used within the silos inadvertently guides research in ways that emphasize the uniqueness at the expense of seeing the commonalities. For example, financial exploitation is considered a possible unique form of IPV occurring in older adults (Acierno et al. 2010). “Financial exploitation” is not defined within any other type of violence within research. Yet, crime statistics indicate that children are more likely to be victimized by theft of money and possessions than by other forms of abuse; this may also be financial exploitation (Finkelhor et al. 2013). The commonalities of risk and protective factors across many types of violence, as well as the cumulative impact of multiple exposures to violence and similar consequences for all forms of IPV, suggest the need for a more comprehensive approach. In the next section, an attachment-based approach is provided as a useful framework for integrating what is known about violence across the lifespan. Incorporating a lifespan approach recognizes that society at large, at all life stages, is involved in violence. Furthermore, wide accessibility to violence prevention focused on disrupting common routes to the development of IPV and enhancing common protective factors to increase resilience is needed. The relationship framework used within this chapter is just one perspective for viewing commonalities in risk and protective factors. Other

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important frameworks exist. Examples include the evolutionary perspective that aggressive behavior confers positive benefits to individuals and society and the patriarchal perspective that men keeping power and control over women supports continued violence.

The Lifespan Context of Violence Examining the lifespan context of interpersonal violence (IPV) reveals, that whether in childhood (Felitti and Anda 2010), adolescence (Lätsch et al. 2017), adulthood (Zapata-Calvente et al. 2019), or older adulthood (Ramsey-Klawsnik and Heisler 2014), polyvictimization is common. At all ages, exposure to one form of violence increases the likelihood of exposure to other types of violence, both in and outside of the family (Finkelhor et al. 2013). Indirect exposure, such as witnessing IPV at home or within the community, is also harmful across the lifespan (Cronholm et al. 2015; Robinette et al. 2018).Violence in the home and dating violence are related to substance abuse, acts of violence in the community, and gender inequality ((Parker et al. 2016a; Zapata-Calvente et al. 2019). When violence exposure is assessed across the lifespan, incidents of violence can lead to continued victimization, perpetration, or both. All these factors can result in changes in risk for perpetration or victimization across time. For example, trajectories for perpetration are not homogenous over time; for example, as Orpinas et al. (2017) found, some perpetrators who engage in low or no rates of perpetration in the sixth grade are found to continue to engage in low or no acts of perpetration in the twelfth grade, whereas others who engage in a higher rate of perpetration show an increased trajectory of aggression between sixth and twelfth grade. Furthermore, engaging in one type of perpetration is associated with an increased odds (1.5–4 times) of engaging in another form of perpetration (Klevens et al. 2012). Youth who are violent in one context or are victims of violence in more than one context are more likely to be at increased risk for future violence. In addition, the consequences of different forms of violence include similar mental and physical health problems, increased risk for depression, suicide, PTSD, and so forth (Merrick et al. 2019; Orpinas et al. 2017; Parker et al. 2016a; Wilkins et al. 2014). Exposure to violence in early childhood can lead to a negative cascade of poor emotional, cognitive, and behavioral regulation and continued violent attachments across the lifespan. Outside of intrapersonal and family factors related to violence, there are socioecological factors at various levels of society that fuel violence such as gender-role inequality, poverty, and racism. However, family, social, and institutional supportiveness are all found to decrease violence (Cornell and Bradshaw 2015). While not all victims become perpetrators and not all perpetrators are victims, the perpetrator-victim pattern may be the most common form of perpetration (Hamby and Grych 2013). Victims and perpetrators of violence can have similar symptom profiles, including anxiety, depression, PTSD, and disorders such as antisocial personality disorder and borderline personality disorder (Spencer et al. 2019). Commonalities across victimization and perpetration start with disrupted

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attachments in early childhood. Understanding the relationship of insecure attachments to acts of victimization and perpetration can help reveal sources for intervention across the lifespan (Fowler and Dillow 2011). Insecure attachments can lead to cascading emotional difficulties (restricted affect, numbing, overarousal), cognitive difficulties (hypervigilance, hypovigilance), physiological problems (arousal in ambiguous or nonthreatening situations), and externalizing or internalizing behaviors (Cromer and Villodas 2017). The understanding that substance abuse can be an attempt to numb memories of childhood adversity opens the door to more integrated treatment of co-occurring substance abuse and trauma, leading to greater success and decreasing health problems such as cardiovascular disease, diabetes, and obesity (Substance Abuse and Mental Health Services Administration [SAMHSA] 2014). While individual, family, social, and larger ecological frameworks for understanding violence are all valid, the following section puts the development of attachments into the foreground of the complex context of understanding IPV to highlight the many points in time where Jasmine’s life might have been saved.

Cascading Impact of Early Violence and Impact Across the Lifespan: Focus on Attachment The intergenerational transmission of violence that led to Jasmine’s death could have started when her mother, Tami, was born and trying to develop a secure attachment to her own mother, or even in an earlier generation when Tami’s mother was born. Interpersonal violence is a relational act that disrupts attachment (Sunirose 2017). Lack of secure attachments is linked to problems such as child abuse and neglect, youth violence, sexual violence, and elder abuse (Wilkins et al. 2014). Direct effects of violence include dealing with the immediate pain, fear, and suffering, while indirect effects include dealing with what other developmental tasks might have been impeded by violence. Problems with attachment may be a key factor across the lifespan leading to more vulnerability to either continued victimization, perpetration, or both (Bonache et al. 2017). Attachment is also the strongest factor in promoting resiliency (Masten 2014). Even in older adulthood, greater social contact decreases the likelihood of abuse (Acierno et al. 2010). In the following discussion, the impact of attachment failures at each life stage is briefly discussed.

Attachments in Infancy Imagine Tami as an infant, crying the same way that Jasmine cried and being ignored by her mother. Tami’s cries become shriller as she tried to get her mother’s attention. A shadow crosses Tami’s face as her mother stands over her crib. Before her mother does anything, infant Tami hears a loud crash that causes her to go immediately quiet – she’s scared. Tami may have just heard her first episode of IPV going on between her parents.

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Neglect and abuse by a caretaker result in great stress for an infant. Although mild or brief levels of stress can support brain development, chronic stress prevents the body from returning to a resting state after a powerfully negative experience. Stress activates the fight or flight response that can disrupt an infant’s ability to develop emotional regulation and to solve problems in the moment; this is referred to as toxic stress (National Scientific Council on the Developing Child 2014). Infants can then become hypo- or hyper-responsive to stressful stimuli. A hypo-responsive infant or child failing to recognize the warning signs of a possible negative cannot avoid it. A hyper-responsive infant may interpret even a neutral event as dangerous and develop aggressive responses. Thus, neurocognitive, affective, and psychosocial development are disrupted by violence (De Bellis et al. 2013). Caregivers who help infants develop secure attachments serve as role models for empathy and start the process of helping children develop positive relationships with others (National Scientific Council on the Developing Child 2014).

Attachments in Early Childhood Tami, in her own infancy, may have learned to not cry as nothing came from her tears. However, if she was quiet, she would eventually be fed. She may have learned that when hungry it was better to not ask for food, for if she did, her mother or father would slap her hard on the face. Tami would have learned to be numb to her early signs of pain, hunger, and loneliness. She learned to be very quiet and still. Repeated victimizations influence children’s emotional responsivity, ability to form trusting relationships, ability to think before they act, and ability to learn from their experiences as they develop, setting the stage for a cascade of negative impacts (Cole et al. 2013). Learning from parents may include how to develop personal boundaries; develop trusting relationships; control emotions, thoughts, and behaviors; and communicate their needs and wishes. The development of these emotional and cognitive regulation skills is key to later success in school and with peers. Children in kindergarten may show poor impulse control, but under normal circumstances show an ever-increasing ability to stop and think before acting when adults provide the scaffolding needed to develop these skills (Masten 2014).Young children repeatedly exposed to violence may show hyper- or hypo-arousal in school. Those who are quick to experience anger or anxiety may be rejected by peers; this might have been Jasper’s pattern. Rejection might have led Jasper to becoming increasingly angry and aggressive; his learning might have been inhibited by his hypervigilance for signs of danger. On the other hand, Tami might have shown another pattern common among abused children; her constant state of fear might have led her to withdraw into herself. This withdrawal might have made her invisible to peers. Teachers reported that abused children had poorer socialization and hesitate to speak in class or about their abuse; Tami might have a greater focus on being very still in class than in learning (Sunirose 2017).

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Children exposed to violence may show externalizing responses to violence, such as refusing to follow rules, bullying, or victimizing others. Others may show internalizing responses like increased anxiety, social withdrawal, or depression. Some children demonstrate resiliency in the face of trauma exposure, such as doing well in school or other activities. Overall, children exposed to adverse childhood events have more problems succeeding in school, develop more psychological difficulties, and are likely to become increasingly socially isolated (Borofsky et al. 2013). Children need to learn emotional regulation and effortful control through positive relationships with older and more experienced individuals. Without these positive learning experiences, they are at greater risk for engaging in impulse reactions and violent problem solving in intimate relationships as they develop (Eisenberg et al. 2014).

Attachments in Adolescence Imagine Tami and Jasper as adolescents. Given their childhood histories, they are likely to have poor attachment skills, but still desire peer relationships. Jasper might find relating to Tami rewarding because she was submissive to his coercive sexual behavior, use of intimidation, and physical control tactics to get his needs met. He may have learned these tactics from observing his father interacting with his mother. Media and social influences may have rewarded his use of hypermasculine behavior in their relationship. Tami may have learned from her family and society that Jasper’s domination and control in their relationship were normal. Relationships with peers become predominant in adolescence. Teens experiencing highly neglectful or violent homes do not receive effective emotional coaching from their parents. Thus, they struggle to know how to understand and regulate emotions and may continue to experience excessive conflict with teachers at school and peers as a result. Without an understanding of what adequate family functioning means, they may not understand the difference between disagreeing, fighting, and being violent. They can have problems directly related to the traumatic experience, such as avoidance of specific places, experiences, people that may trigger memories of trauma, and the development of aggressive, sexualized, or other maladaptive behaviors. A combination of violent role models, poor parental monitoring, and involvement with deviant peer groups is likely to result in poor academic achievement, earlier sexual activity, increased substance abuse, and involvement with the criminal justice system (Ryder 2014). Without the protective factors that stem from positive relationships, as teenagers begin to spend more time trying to develop their own identity, they may believe that they deserved mistreatment from their parents and engage in maladaptive behaviors in response to anger, resentment, and hostility. Jasper and Tami may both abuse substances now. This may increase Jasper’s impulsive, risktaking behavior. Tami may find substances numb her feelings of fear, depression, and self-blame for the violence in their relationship.

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Attachments in Adulthood In adulthood, because they have maladaptive attachments styles, Tami and Jasper are likely to be an explosive couple. Tami may try to pull Jasper closer to her when he is trying to establish some interpersonal distance; this act of wanting some distance activates her fear of being alone. Thus, he may only gain the distance he needs after he violently assaults her. This is the type of destructive give and take that can lead to a cycle of violence. Despite repeated injuries, Tami might still view Jasper as her closest emotional connection. Coercive control is often used by one partner to control the other, even after divorce (Elizabeth 2015). Additionally, insecurely attached adults may become parents who do not know how to foster a secure attachment with the next generation. Mothers with exposure to IPV are more likely to show a bias toward interpreting infant emotion cues as fearful, a bias that is associated with more internalizing symptoms over time (Bernstein et al. 2019). Parents in maltreating households tend to use harsh physical discipline when children make mistakes or misbehave, thus modeling unhealthy behaviors for the children, contributing to the intergenerational transmission of violence.

Attachment in Older Adulthood Older victims show the same pattern of co-occurrence and polyvictimization found in younger age groups (Rosay and Mulford 2017), and the insecure attachment styles developed will persist. If Jasper and Tami lived together as older adults, Jasper is likely to continue using violence and coercive control to keep Tami jumping to his slightest commands. In the absence of social support (i.e., healthy relationships), abuse or neglect is highly likely (Acierno et al. 2010) Older adults can be helped with their increased health problems by supportive family. However, for Jasper and Tami, their son, their only remaining family, may be incapable of assisting them because of his own attachment issues that result from growing up in a hostile family. He might have been in extended foster care until he became 18. Unless he had received very effective foster care, he might now be a violent adult, having modeled the behavior he observed in Tami and Jasper. Due to their abusive behavior directed at him, and his witnessing of Jasmine’s death, he might feel disconnection and even hatred for them. The likelihood of him caring for Jasper and Tami in their older adult years is low. If he has not abandoned them to their fate, he might victimize them now that he is in a position of power over them. He is unlikely to view society as having played a role in his lifelong history of violent relationships.

Lifespan Versus Incident Approach to Understanding Violence Exposure Secure attachments are critical to healthy functioning across the lifespan; however, abuse interferes with the formation of these attachments. In addition to supporting the development of healthy relationships, preventing violence requires interventions for

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the indirect consequences of violence, including the many critical academic and social skills that may be deficient. The older the person is before interventions are offered, the more deeply entrenched the maladaptive skills might be. If treatment professionals had intervened when Jasmine was 3 months old, she would have needed less help than Tami and Jasper in developing secure attachments and recognizing the signs that they were safe. Grandparents, if they became involved, would need even more help. No individual or system wanted Jasmine to die or for her parents to have no future but prison. However, many professionals crossed paths with Jasmine and Tami, and their desperate need was either unrecognized or not adequately responded to. A lifespan versus incident approach would support the development of positive attachments for all family members; this type of approach might have changed the trajectory of this family. Jasmine was conceived by parents who abused substances and had no readiness to help her develop a secure attachment to them or her brother. Professionals need to shift their viewpoint from addressing the incident on the referral sheet to addressing the negative impact of violence exposure across the lifespan of the individual coming before them. Hypothetically when Tami arrived at the hospital to give birth, she would be screened for all exposures to violence. Learning that she was repeatedly victimized as a child, the current victim of IPV, and taking illegal substances, many services would have been offered to her. While Tami might have refused the services of a domestic violence advocate, the appearance of this person at the hospital could have shown Tami that members of society cared about her welfare; she wasn’t invisible, white trash, or the scum of the earth. Tami might have been offered services for caring for Jasmine both in and out of the hospital through the Nurse-Family Partnership. She might have refused this help, fearful of what a nurse might see in her home. However, she now knew this service exists. When she found parenting two children caused her severe anxiety and stress, she might have reconnected with the hospital to get this help. Rather than responding to Jasmine’s death with a criminal justice solution, the family needed a multidisciplinary team of professionals to provide comprehensive services including substance abuse, mental health, and parenting skills for the parents. Their son might need to be in therapeutic foster care receiving medical and psychological services until Jasper and Tami could provide a safe and caring environment. Tami and Jasper might have agreed to treatment in lieu of time in prison. If they received social support for Jasmine’s death and nonjudgmental responses to their poverty and lack of job skills, they might have developed hope they could live without being numb. These comprehensive services would come at a cost. However, the current approach to responding to violence after it occurs costs billions of dollars (Fang et al. 2012). Many evidence-based practices are available for increasing resilience in individuals and families that could end the intergenerational transmission of violence.

Public Health Approach A public health approach recognizes the complexity of IPV and is committed to moving beyond silos and incident-based approaches to a more holistic and lifespan approach. Furthermore, a public health approach acknowledges macro-level factors,

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i.e., institutional betrayal, such as racism, sexism, and ableism, within society that leads to increased exposure to violence with its negative impacts on psychological and physical health (Felitti and Anda 2010; Cronholm et al. 2015), and is committed to using evidence-based practices to best serve communities. As such, this approach requires expertise from multiple disciplines and emphasizes the centrality of multidisciplinary teams (MDTs). MDTs, which are discussed in more detail in the next section, have the capacity to make flexible decisions in complicated situations and serve as the vehicle for implementation of the public health approach. For example, rather than punitive punishments, probation could monitor mental health, substance abuse, parenting, and employment support for Tami and Jasper (Duwe and Clark 2017). Proactive action requires interdisciplinary colleagues who can recognize warning signs and develop a coordinated plan. It also includes a commitment to pluralism, with everyone gaining full access to education, medical care, and justice (NPEIV 2017; Wilkins et al. 2014).

Multidisciplinary Responses to Violence Currently, society reacts differently to aggressors of IPV depending on the context in which the violence occurs. If the aggressor serves in a “caregiving role,” then child protective services (CPS) may become involved (Child Welfare Information Gateway 2019b). If violence occurs between an adolescent and another adolescent, not within a caregiving relationship, then the police may become involved. If violence is between a child and older adult, then adult protective services may become involved. Recognizing that perpetrators commit different types of violence and victims may suffer from more than one type of abuse indicates that professionals working with violence need to have diverse skill sets. The collaborative efforts of professionals working together bring a greater variety of strengths to the table and allow a more comprehensive approach to violence prevention. Building connections to form multidisciplinary teams (MDTs) requires a shift in the manner that criminal justice, educators, medical professionals, social service, mental health, and social/political leaders carry out their responsibilities. MDTs are “people with distinctive professional skills, background, knowledge, and expertise who come together to work on collective tasks” (Liao et al. 2015, p. 965). MDTs can increase the information available, including “1) a broader range of expertise and a more extensive network of professionals; 2) additional opportunities for sharing data and using data for action; 3) expanded knowledge of other resources and networks; and 4) increased options for the field to more quickly learn about innovations, which could increase uptake and maximize impact” (Wilkins et al. 2014). The success of MDTs is dependent on characteristics of those within the team, as well as commitment to the team. MDTs and resource persons should be identified and introduced before incidents occur. Trust does not automatically occur between helpers and people who come before them. Similarly, members of MDTs do not automatically develop trust for working together. Building trust requires transparency of communication and actions (Wilkins et al. 2014). It is important for

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members to be dedicated to the process of working collaboratively with other members. Team members need to remain focused on ending violence, not enhancing their own professional identity to support the collaborative power of an MDT (Liao et al. 2015). Establishing a positive climate in the relationship between members of MDTs where everyone brings unique perspectives and skills to the table is associated with successful outcomes (Goicolea et al. 2019). It can also be of value in preventing secondary traumatic stress and burnout (Dir et al. 2019). The complex context of violence that includes victims, perpetrators, and victimperpetrators, of all ages, as well as family members and the larger community, needs the expertise that MDTs can provide. This approach cannot be effective if members of the MDTs do not have proper training. Currently, most first responders learn “on the job” how to respond to cases of violence. The impact of this includes inadequate or inappropriate service delivery to some victims and perpetrators, as well as a high rate of burnout and secondary traumatic stress within the workforce (Dir et al. 2019). However, professionals are often not trained in how to work together with other professionals. Mason et al. (2017) have a training program focused on deepening knowledge, beliefs, and skills for working together rather than separately when in the immediate situation of IPV, also providing substance abuse treatment or mental health services. The program includes ten core competencies considered critical to professionals working with IPV and other mental health and substance use issues. Professionals with this training show increased knowledge of the complexities of IPV and value interdisciplinary networks. While this is an important step forward, their curriculum is intended to focus on interconnections for those working with IPV but does not address concerns that might arise when cases span many developmental periods. It is essential that all professionals receive experiential training on how to recognize and intervene in cases of IPV prior to needing these skills in actual cases (NPEIV 2017). Shifts in the roles of many professionals will be needed if a proactive and comprehensive public health approach is taken to end the intergenerational transmission of violence (NPEIV 2017).

Shift in the Role of Criminal Justice A public health approach recognizes that the criminal justice system may serve as a secondary source of violence prevention through focusing on rehabilitation to prevent recidivism and support restorative justice (NPEIV 2017). This approach may be more effective in reducing future acts of violence than current practices. Restorative efforts are also generally associated with higher victim satisfaction (Wilson et al. 2017). There are many choice points in the criminal justice system where diversion programs can have value (Steadman et al. 2016). Since problematic behaviors may cluster, working to prevent recidivism of crime may be enhanced by intervening with services for offender mental health problems, violent relationship strategies, substance use, and educational and vocational needs (Orpinas et al. 2017). This multidisciplinary team approach could allow some offenders to be involved in rehabilitation services while on probation, rather than while incarcerated. They

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would receive screening for violence exposure as well as their educational, mental health, and substance abuse needs, and a trauma-informed rehabilitation plan would be developed. The offender’s progress would be monitored by the MDT led by the probation officer. There is evidence that some diversion programs may be successful for even medium- and high-risk offenders when probation officers, judges, and mental health practitioners collaborate (Heilbrun et al. 2017). Information from a violence and trauma exposure screen can be a valuable part of the standard presentencing report that judges use in determining what education or rehabilitation services are appropriate for an individual. Using diversion programs for offenders with mental health problems can decrease societal costs from both recidivism and direct prison expenses. Highly violent individuals may still need prison in order to protect society; however, prison needs to be a safe environment with inmates screened for violence exposure and receiving evidence-based treatment to promote rehabilitation. A public health approach recognizes that reducing the risk that an offender will re-offend, requires a lifespan versus incident perspective to their exposure to violence. Due to the complex context that supports violence, a multidisciplinary team approach to screening for rehabilitation needs and monitoring safety of the offender is needed. Incarceration includes ripple effects on families that can lead to decreased emotional and behavioral functioning in children, food insecurity, and living in dangerous neighborhoods, putting children of offenders at higher risk of victimization. Providing services that strengthen family relationships, build safety within the family unit, and increase employment opportunities may reduce the intergenerational transmission of violence as it allows the offender to participate in activities that may provide restorative justice to victims and their families.

Shift in the Role of Educators A public health approach recognizes that schools can serve as primary prevention of violence if they proactively integrate evidence-based social and emotional skill building into the primary and secondary school curriculum. MDTs involving educators and mental health practitioners could work together to ensure at-risk youth and families get any additional services needed for learning how to develop positive attachments and engage in nonviolent problem solving; evidence-based treatments are currently available, although not widely implemented that can help. Schools need to employ psychologists as part of the school staff to teach social skills and problem solving throughout the early and later school years and intervene when mental health issues arise (NPEIV 2017). Teachers in training could specialize in teaching social skills, increasing empathy, and problem solving as they now do in preparing to teach English or science. Increasing their students’ positive attachments across the lifespan supports ending the intergenerational transmission of trauma. Colleges and universities could ensure that all students training to be first responders to cases of IPV receive skill-building in trauma-informed care before they enter the workforce. Judges, physicians, psychologists, and religious leaders

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need to receive graduate training in understanding violence and skills for providing evidence-based and trauma-informed care. Continuing education for those already in the workforce is needed. There are evidence-based programs and forensic interview protocols available to help support effective MDTs in their work such as Child First, National Children’s Advocacy Center, and the National Institute of Child Health and Human Development. These programs are effective because they provide intensive trainings and continuing education. Thus, there is a cost in terms of money and time, but they also lead to increases in job effectiveness and reduced turnover.

Shift in the Role of Medical Professionals A public health approach views medical professionals as key to primary prevention of violence. Most people, across the lifespan, will have contact with a medical professional. If screened for violence exposure, medical professionals could ensure that many more people receive the comprehensive and evidence-based treatments they need than having these made available only to individuals who come to the attention of the police, child protective services, or older adult protective services. Medical professionals need to shift their roles from screening only a lifespan history of family medical illnesses to also screening for a family history of violence exposure. To do this, they need to receive training for recognizing and responding effectively to cases involving violence; this is rarely available currently (NPEIV 2017). They also need training in how to work as members of multidisciplinary teams that include the capacity to provide biological, legal, psychological, and social interventions when needed to comprehensively respond to cases of IPV. To be effective medical professionals will need training in trauma-informed care. Hoysted et al. (2019) found that a 15-min online training about trauma-informed care designed for medical providers significantly increases their knowledge, including at a 1-month follow-up. Evidence-based treatments for hospitals include sending nurses to visit the homes of at-risk families, as this reduces rates of child abuse and neglect (Commission to Eliminate Child Abuse and Neglect Fatalities 2016).

Shift in the Role of Social Services Social service agencies are part of secondary prevention efforts within a public health approach. They intervene in cases already identified as at high risk for violence. As familial problems are often intergenerational and chronic, social service workers need to shift their perspective to a lifespan versus an incident approach and address violence exposure within all family members and build resiliency of all family members (Fedock et al. 2018). MDTs are not new to child protective services. They are increasingly used to plan treatment for their most difficult cases and include highly trained forensic interviewers at Child Advocacy Centers (CACs). These centers are designed to be child centered to reduce the stress on children and youth who are being interviewed and to increase accuracy and depth of information gained

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in the interview process (Cross et al. 2007). Research indicates that CACs increase cohesion and communication in the forensic interviewing process, a highly important consideration due to the sensitive nature of the interviews. Further, compared with other cases that do not use them, CAC cases use MDTs to collaboratively interview as one part of a more “child-oriented” response to reports of abuse (Cross et al. 2007, p. 1050). This use of trauma-informed care (Bartlett et al. 2018) increases the well-being of children with complex trauma within the welfare system. The strategies that CACs are using in cases of child sexual abuse need to be expanded for use with victims of violence across the lifespan. Whichever social service worker hears or sees a warning sign of violence, collaboration with an MDT needs to start. A lifespan screening of violence exposure needs to be carried out, and the types of interventions needed to move this entire family toward safe and healthy functioning need to be determined; this is the comprehensive public health approach that is more likely to break the intergenerational transmission of violence.

Shift in the Role of Mental Health The public health perspective recognizes that violence is a public health crisis, not a specialty area within psychology for certain disorders. Mental health workers provide services that are secondary prevention efforts within a public health approach. Their clients come in for services for a wide variety of emotional, cognitive, and behavioral problems, substance abuse problems, and psychiatric issues. They all need to be screened for violence exposure as the issues that bring them to treatment put them at higher risk for violence than the general population. Mental health workers need to become part of diverse MDTs. They need to work with educators and children and youth workers to provide trauma-informed support to schools. They also need to work with police and probation officers to provide trauma-informed services for the judicial system. They need to work with older adult protection workers, nursing home administrators, and medical professionals to provide trauma-informed care to older adults. They need to partner with faith communities and law enforcement to respond effectively to faith-based abuse. Whatever the age of victims and perpetrators who come to the attention of mental health workers, there are common factors that support resilient functioning including building positive attachments, learning emotional regulation skills, and nonviolent problem solving. The use of MDTs, when their cases involve violence exposure, can strengthen the effectiveness of their services. Accessibility to mental health services has increased over time due to the Mental Health Parity and Addiction Equity Act of 2008 and the Patient Protection and Affordable Care Act of 2010, which expanded programming and insurance coverage of broader services (National Academies of Sciences, Engineering, and Medicine 2018). However, barriers to participating in mental health treatment still exist. A public health approach can help reduce the stigma that prevents many people for accessing mental health services. Treatment services can be viewed as increasing resilience or as inoculating the population to

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decrease vulnerability rather than as specialty services for the mentally ill. Treatments offered to clients should be based on research showing their effectiveness. Currently, there are two websites for finding evidence-based treatments. One is maintained by the American Psychological Association (https://www.div12.org/ psychological-treatments) and the other by the Substance Abuse and Mental Health Services Administration (https://www.samhsa.gov/ebp-resource-center).

Shift in the Role of Policy Makers/Politicians It is unusual to think of policy makers and politicians, whether at the local, state, national, or international level, as part of the public health approach to IPV. But they are. They often are in the most powerful position to get things done, whether through legislation, issuing regulations, or setting budget priorities. Efforts to fund violence prevention initiatives are scattered across different areas, such as effective policing initiatives or the development of Child Advocacy Centers. The public health crisis of violence requires a shift in the role of local, state, and federal policy makers to integrating violence prevention throughout their initiatives for public welfare. Common issues across the research on violence include children of color getting less medical care, living in more dangerous housing, receiving poorerquality schools, and receiving less effective policing. Thus, when tough financial decisions need to be made, more resources should go to disadvantaged communities (NPEIV 2017). For guidance in developing more effective policies, local officials need to engage local groups such as domestic violence and sexual assault centers, child protective services, as well as groups such as NAACP, Mothers Against Drunk Driving (MADD), Rotary Clubs, humane animal welfare advocates, church groups, the YMCA, and others to provide pro bono services to increase the safety and social connectedness of their communities (NPEIV 2017). Government agencies at all levels need to provide funding for the provision of evidence-based prevention in order to disrupt the intergenerational transmission of violence. Integrating services might reduce costs. For example, instead of clearinghouses for each type of violence, there could be an integrated agency and clearinghouse for violence across the lifespan. Leaders need to encourage and fund the use of MDTs in their communities. These teams can be responsible for bringing trainings on traumainformed care to their communities and educational programming on how to use best practices in intervention. MDTs can inform local, state, and national leaders about current evidence-based practices and costs so that leaders can make informed decisions about how to spend limited financial resources. An MDT might determine they have enough practitioners to meet the needs of child and adolescent victims but not enough expertise available for older adult victims. Proactively reaching out to officials who might be able to offer incentives to bring more of these practitioners to their community may prevent crises down the line. Public officials need to recognize the large societal cost that will come from failing to respond to the impact of adverse childhood experiences on their

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communities. The Child Abuse Prevention and Treatment Act (CAPTA) (Children Welfare Gateway 2019a) was passed in order to prevent the violence and neglect that Jasmine and her brother experienced. However, according to Palmer and Huseman (2019), this highly complex piece of national legislation is not fully enacted anywhere in the USA and is only fully complied with when a child is taken out of parental custody. Instead of receiving proactive medical and social service help after Jasmine’s birth, Tami remained addicted to drugs and overwhelmed with parenting. After killing Jasmine, Tami was sent to prison; Jasmine’s brother saw her being murdered, setting him further on the road of the intergenerational transmission of violence. The Centers for Disease Control and Prevention has a strategic vision to “connect the dots” between forms of IPV (Wilkins et al. 2014). This vision can be used to help policy makers recognize the critical need to intervene with evidence-based practices to decrease the common risk factors for violence and increase the protective factors that could prevent violence across the lifespan. Additionally, the United Nations (n.d.) offers suggestions about preventing violence against children through laws that address underlying causes of violence rather than focusing solely on acts of violence. Regulation of and limitations on harmful alcohol or substance abuse, for example, can substantially impact rates of violence (United Nations n.d.). For this reason, local officials and those involved in the political realm can reduce rates of violence at many points in the chain of occurrence, including legislations that address problematic precipitating factors that may be linked to violence. Funding is most cost-efficient when it targets reducing risk and protective factors related to violence across the lifespan (NPEIV 2017; Wilkins et al. 2014). A public health approach to preventing violence places local, state, and national leaders as able to initiate primary prevention steps to end interpersonal violence; they would recognize the social and political forces that serve as scaffolding for interpersonal violence and break them apart. The political system is intended to ensure the welfare of all individuals within local, state, and federal jurisdictions. However, individuals from high socioeconomic groups are more likely to have political influence than individuals of lower socioeconomic status; the bulk of financial support for political campaigns comes from older, more conservative, White Americans. Preventing institutional betrayal requires the development of procedures, rules, and laws that are fair and just and serve all citizens regardless of their age, developmental or acquired disabilities, gender, nationality, race/ethnicity, sexual orientation, and socioeconomic status or ability to gain access to political leaders (Wilkins et al. 2014). Vulnerable communities need a greater share of resources for strengthening community support when budgets are tight (Wilkins et al. 2014). They can ensure that primary prevention occurs across the institutional, social, family, and personal levels. They can fund programs to support nationwide recognition of the warning signs of violence using regular parts of radio, television, and media public service announcements. They can fund programs that use evidence-based initiatives for secondary prevention of violence.

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Key Points • Different types of interpersonal violence are interrelated with each other. • Interpersonal violence across the lifespan shows dynamics of insecure attachments, power, and coercive control. • Poor attachments, emotional dysregulation, and violent problem solving are common in victims and perpetrators. • Ecological factors of gender inequality, income inequality, lack of access to medical care, and institutional betrayal support interpersonal violence. • The lifespan versus incident approach is key to disrupting intergenerational transmission of violence. • Multidisciplinary responses offer more comprehensive interventions. • Public health responses using evidence-based practices need funding.

Summary and Conclusions Research shows most acts of interpersonal violence involve a web of interconnecting risk factors that can begin as early as the prenatal period when a child is conceived by parents who are not prepared and do not know how to ensure the health of the developing child. When an incident approach is used, those investigating operate within one slice of time. As discussed throughout this chapter, the tragedy of Jasmine’s death underscores the many failings of the past siloed approach to cases of violence. The interconnections between many forms of violence within Jasmine’s life can serve to remind professionals that, whether they have been trained to work with children, teens, or older adults, they have a common cause. Everyone in the USA is touched by interpersonal violence through causes as diverse as bullying in the schools, sexual abuse by clergy, or the murder of a pet. If everyone working to end violence, anywhere across the lifespan, works together with one voice, the messages are greatly amplified, and leaders may hear the message that violence is a public health risk and can be prevented. The widespread nature and complexity of violence risk requires a lifespan rather than an incident approach to intervention whenever someone comes to the attention of professionals for being a victim or perpetrator of an act of violence. A multidisciplinary response needs to comprehensively address the needs that a history of violence exposure reveals so that a family like Tami, Jasper, and their two children receive the services needed to disrupt the intergenerational transmission of violence. MDTs need to be involved in all cases of interpersonal violence so that diverse professionals can offer different insights into what may or may not be needed by a victim, perpetrator, or victim-perpetrator of violence to end the cycle of violence. While an aggressive teen may not have their own criminal record, giving a police officer the view it is a low-risk case, a repeated history of severe physical and emotional abuse within the files of child protective services can serve as a clear warning sign of a family at high risk.

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As a nation, the USA spends billions of dollars on interpersonal violence across the lifespan (CDC, Division of News 2012; National Center for Injury Prevention and Control 2003). Using education of all forms in the creation of a culture of public health could end the need for this spending. Recognition of the widespread impact of violence across the lifespan calls for making evidence-based interventions accessible to the entire population in need. There are public and private clearinghouses of information dedicated to helping prevent interpersonal violence. Examples include the Child Welfare Information Gateway (https://www.childwelfare.gov/topics/preventing/over view/federal-agencies/) and the National Clearinghouse on Family Violence Content Topic (https://vawnet.org/publisher/national-clearinghouse-family-vio lence). A resource focused on victims who are older adults can be found at https://www.ncall.us/abuse-in-later-life/. If voices are raised in common cause to end all forms of interpersonal violence, cost sharing could make a National Institute of Violence Prevention Across the Lifespan a less expensive yet more effective strategy than these different efforts siloed by age group. It could maintain a national database of resources helping professionals find the services their clients need. This inclusive institute could help organize and fund evidencebased initiatives to end interpersonal violence. The National Plan to End Interpersonal Violence Across the Lifespan includes 22 recommendations for making IVP a rare event (NPEIV 2017). It calls for a coordinated public health approach to ending violence, tailored to the unique needs of diverse communities. It is time to fully implement this plan.

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A History of Interpersonal Violence: Raising Public Concern Stéphanie Pache

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Current Situation: Violence as Harm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Biopolitics of Interpersonal Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Violence as Excess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Violence as Deviance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Violence as Conflict . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Violence as Oppression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Violence as Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

This chapter narrates the history of the social changes that underlay the development of research and policies on interpersonal violence in contemporary North America. The current status of interpersonal violence as a public issue is the product of moral transformations and political actions. Social movements and victims’ advocates played a great role in redefining as morally intolerable some kinds of violence that were previously tolerated, as much as in making public

This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. S. Pache (*) Center for Medicine, Health, and Society, Vanderbilt University, Nashville, TN, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_284

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what was considered a private matter. The chapter describes these processes and the actors engaged in this social justice movement, focusing especially on research and professional projects that supported the recognition of interpersonal violence as a public issue requiring political action. The production of data and studies on the prevalence of violence and its effects on the lives of concerned individuals contributed to raising awareness on this pervasive issue, as well as also framing it as a public health issue. The institutionalization of this scientific and professional activity will be described with a focus on what connects its subfields: a concern for victims and their trauma. This historical perspective shows how raising public concern about interpersonal violence included not only identifying violence and justifying action against it but also reframing it in the languages of social justice and public health. Professionals and researchers have engaged in preventing and disarming interpersonal violence with an expertise grounded in a quest for justice. This chapter teases out these entanglements in the contemporary history of interpersonal violence. Keywords

Modern history · Interpersonal violence · Public policies · Public health · Social issues · Expertise · Psychology · Gender · Activism · Feminism

Introduction Because violence is both a personal and collective experience, it resists neutral and objective definition and assessment. The definition of what constitutes violence is the product of political and moral processes, involving social movements for the rights of the politically excluded. Challenges to violence have indeed created powerful public conversations to bring about cultural transformations. This chapter presents a genealogy of what is currently considered interpersonal violence. It sheds light on the moral and social transformations that occurred during the last two centuries. For those changes to appear as they did during the nineteenth century, many conditions had to be present: claiming a system of rights and protection for the weak requires a powerful and organized institution to obtain them from, and this institution will also have to enact the rules and enforce them, such as a state and a legal system. The recognition of citizenship and of the idea that citizens possessed the legitimacy to be politically active was also necessary. Citizen involvement has been crucial in raising public concern about interpersonal violence and in building the notion of interpersonal violence as it is understood today. This chapter’s goal is to offer a historical perspective on the contemporary focus on interpersonal violence as a public health issue. To understand this strategy to raise public concern, it presents other arguments made to raise public awareness on interpersonal violence across time, revealing thus continuities and discontinuities between the different approaches. The chapter’s focus is on gender-based violence (i.e., mostly intimate partner violence and sexual violence), because of the pioneering role this kind of

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violence played in raising public awareness on interpersonal violence (Rutherford and MacKay 2013; Cavalin 2016). It addresses therefore only briefly child abuse, which is however well-researched by Gordon (1988). Elder abuse is beyond the scope of this history, because it did not shift – at least for now – cultural understandings of violence. In addition, this kind of violence is a contemporary social issue that can probably be understood through the lenses that this chapter presents. Similarly, for the purpose of this chapter, which is to present views on interpersonal violence and their roles in raising public awareness, the human rights perspective on interpersonal violence will be considered as sharing the conceptualizations of violence as harm and/or as oppression that this chapter will describe infra (Gruskin and Butchart 2003). Though it emerges as a perspective with its own path and could be the object of a specific analysis, it can be seen as a specific legal and political strategy, advocated mostly by nonprofit organizations and international governmental organizations, but one that does not offer or support an additional perspective on violence itself. In the modern period, Western societies embraced the belief that their cultures were on a civilization path, though they developed for that purpose the slave trade and colonization. They believed that rationality as embodied by science would help humanity achieve its goal of progress. A social project emerged to rationalize the contradictions between the progress and science ideals inspired by the Enlightenment and the concrete actions of the self-proclaimed “Enlighted” nations. This project was based on the premise that the human species could be made both stronger, i.e., improving its survival, and greater, i.e., confirming its status of “superior species.” Often embedded tightly in evolutionist and eugenicist ideas, this project involved the identification of the “degenerate” individuals threatening it, and sometimes their elimination or reeducation. In the evolutionist as well as in most progressist perspectives, interpersonal violence was perceived as the remnant of the “uncivilized” part of humans and, as such, should be eradicated. The betterment of human beings was, however, rooted in different competing ideologies and took many forms in the social reforms and policies carried out on its behalf. Protestant religious morality combined with the ideology of social Darwinism as developed by Herbert Spencer at the end of the nineteenth century (Browne 2016). These ideas shaped public and political institutions, including education, health, and legislation programs. From a nineteenth-century moral and economic concern for the species’ survival and the social sharing of resources, the issue of interpersonal violence gradually became almost exclusively a question of justice and health through the creation of the category of victim and its social recognition. This is most evident during the three last decades of the twentieth century. The social movements of the 1960s and 1970s started to link violence and authority in general and criticize both. These movements built the foundations of the legitimacy of denouncing the use and abuse of violence. Individuals and social groups could then seek protection and reparation on the behalf of their status as victim of violence and oppression. The ideal of progress nevertheless still resonates in contemporary discourses when some wish for the eradication of all interpersonal violence that “still” exists, as if there would be a natural process that would put an end to this

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human behavior. In this context, a new consideration, biopolitics, emerged to support a systemic intervention in the lives of citizens. Biopolitics refers to the means used to “put their lives in order” as a mechanism to support a commitment to improving humans and society (Foucault 2008). It assumes that the social production of individuals is affected by their education, in particular in the family and at school, by the care that they receive from health professionals and social workers, and by the legal and institutional norms that delimit the scope of tolerated behaviors. Biology, psychology, and medicine contribute greatly to the definition of those sanctioned behaviors, creating categories of normalcy, which encompassed both what is statistically frequent, i.e., “standard,” and what is considered not pathological, i.e., “healthy.” The growth of biopolitics and the spread of the ideals of civilization and progress have been historically linked in the modern period. The first offered means to advance the second. But biopolitics remain politics and, consequently, a place of conflict. The treatment of violence evolved in this moving space delineated by institutional policies, knowledge production, and social movements. This chapter describes what place was given to interpersonal violence, or some kinds of interpersonal violence, through these social phenomena and their connections. The genealogical perspective on the contemporary approach of violence as a public issue, and especially of interpersonal violence as a public health issue, explains that this history considers in particular how medical and psychological science has developed as one of the main areas of expertise about violence. Through the narration of episodes in history where public concerns were raised on violence, this chapter shows the role of medical and psychological views on interpersonal violence and therefore also constitutes a history of the psychological and medical science about violence. In the sections that follow, the chapter first discusses the current situation of violence as harm. Subsequent sections then explore the changing views of violence, first as excess, then as deviance, conflict, oppression, and finally as trauma. These changes in the way that interpersonal violence was perceived in the modern period are presented here in their chronological order of appearance and with a focus on North America. These conceptions of violence and the related public concerns must not be understood as exclusive – nor universal. All these approaches, despite their emergence in different contexts, coexist or are even combined, in the scientific field and society at large, although other approaches have emerged subsequently to challenge them.

Current Situation: Violence as Harm Whereas other human and social science fields have more contextualized and variable definitions of violence, psychology and health disciplines have now generally adopted the World Health Organization (WHO) definition of violence: “Violence is the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment

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or deprivation” (WHO 2014, p. 84). Violence is then qualified as interpersonal when it is perpetrated “by a person or a small group of people against another person or small group” (WHO 2014, p. 82), which, as the WHO describes, occurs between family members, intimate partners, friends, acquaintances, and strangers and includes child maltreatment, youth violence, intimate partner violence, sexual violence, and elder abuse. This conception of violence delineates it by the effects it can have, as much as the intentional character of violence. Interpersonal violence is also distinguished from self-inflicted violence and collective violence (i.e., violent conflicts, gang warfare, terrorism, mass displacement). In this global health perspective, violence is seen through the injury model of pathology, as the association of violence prevention with injury prevention underlines. The public health duty to prevent violence is justified by the health effects of violence, i.e., the harm done, whether physical or psychological, whether the threat became real or not. The definition of violence by its effects allows the WHO and public health researchers to encompass in this expression various types of violence emerging in different contexts and motivated by different reasons. In addition, though the WHO definition of interpersonal violence appears to only delineate a “sector” of the general issue of violence by a criterium that could be read as purely quantitative, the given examples list violent phenomena that require a qualitative distinction to analyze them and discuss answers. This definition has two corollaries: first, it subscribes to the moral opinion that a behavior is violent when it is intended and directly harmful to its victim(s); second, the recognition of psychological trauma as a sign of a violent event extends the definition of violence to a wide range of behaviors and experiences. The health perspective on violence can be summarized under the expression “violence as harm.” Conforming to the traditional goals of public health to prevent health damage and organize healthcare, the risk of harm grants public health its legitimacy in the matter of violence. Though this framing can be perceived as logical and matter-of-fact, it results historically from social transformations of the cultural representations on interpersonal violence. The “violence as harm” perspective was provided both by social movements fighting against oppressions and discriminations and by research studies supporting this struggle for social justice.

The Biopolitics of Interpersonal Violence The historical understandings of violence are all concerned with the social effects of interpersonal violence, but the first, labeled “violence as excess,” which developed during the nineteenth century, is framed in broader and more abstract issues such as population growth and resources, progress, civilization, and the survival of the human species. At the beginning of the twentieth century, the concern about the social effects of violence was more limited and concrete. What worried citizens and legislators was crime and delinquency, until the rise of social movements in the 1960s that contributed to create a legitimate status for victims.

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Violence as Excess During the nineteenth century, the evolution of political sensitivities and concerns in the West led to a movement against cruelty to animals, then to children, and also, but less distinctly, to women. The first-wave feminist movements, which at the end of the nineteenth century in the United States worked to obtain women’s right to vote, were linked to other social movements: in particular the Social Purity movement, which focused more specifically on “sexual purity,” as well as temperance movements, another network promoting moral and social reforms regarding alcohol consumption and its prohibition. The members of these movements supported the eradication of behaviors and social problems that they thought represented moral depravation and contravened social progress. These vast and heterogeneous movements agreed on a growing concern, the lack of self-control in men, as illustrated by sexual or physical violence, as much as by alcohol consumption, and the latter was understood as the enabler of the former issues. The denunciation of family violence, rape, and prostitution was part of their campaign for moral reforms in accordance with their political and religious project. The denunciation of violence against women started with a focus on prostitution and rape (D’Emilio and Freedman 1988; Freedman 2013). This discourse linked these issues with the fear of the transmission of venereal diseases, but also with the eugenicist concern about the intergenerational transmission of bad morals. Though domestic violence was known and mentioned in political and legal documents, it was in this context the subject of less criticism and activism. Historians relate this exclusion to the question of divorce: some of the activists who criticized domestic violence associated this critique with a defense of the right of abused women to divorce. Other critics wanted to distance themselves from that claim. Most of the women involved in social reforms of this period defended a conservative Christian perspective on family, and they did not want to help justify divorce or at least did not want to give priority to this claim over other political goals. This perspective on “violence as excess” was supported in its civilizing mission by some interpretations of the theory of evolution, which was developed by biologists, most notably Charles Darwin, concerning animals and plants. The observation of nature led evolutionist biologists to describe a high degree of inter-individual variability. This inter-individual variability was positively perceived as a necessary condition for the selection process of evolution, in which the best variants of the species survived. However, this doctrine also admits that nature produces variants considered harmful to the progress of the human species, which humans could therefore help to eliminate or improve. For the tenants of social Darwinism, these “bad seeds” are the product of a degeneration process and could explain the wrongs and the mishaps in a population. In this approach, even if a problematic behavior was only a quantitatively limited phenomenon, it should nevertheless be eliminated for the sake of the species. Violence against women was however not necessarily considered problematic. Wife beating was tolerated and legal in most nineteenthcentury legislations as long as the assault was not lethal and the level of violence was kept within certain limits (Siegel 1996; Peterson del Mar 1996). In addition, the

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idealization of nature by several evolutionists led them to defend the claim that human behaviors were mostly biologically determined. They believed that male aggressiveness was useful to the evolution and reproduction of the human species (e.g., Paul 2003). Male violence had been and still is often naturalized and explained by sexual biological differences (e.g., Longino 2001; Tosh 2011). Aggression has been studied since the nineteenth century in humans and animals through the lens of biological determinism. Theories about the mechanism of biological determination fluctuated. Genes, hormones, and the brain were considered successively as valid explanations of human behavior. Though no data validate the hypothesis of the biological origin of male violence, the persistence of this claim resulted in numerous studies and analyses challenging it (Longino 2013). This perspective on “violence as excess” was interested primarily in unnecessary cruelty due to lack of control and was thus centered on the aggressor. It did not take into account the victim or the situation in which violence happened in order to understand and prevent it. This approach criticized violence as a sign of moral degeneration, which was conceptualized in several ways: degeneration as a moral or social process that was “correctable” (through education, improvement of social conditions, alcohol abstinence, etc.) or degeneration of the biological material of the specimen itself (or part of it), which would require different kinds of correction or strategies to avoid reproduction (e.g., sterilization, surgery, medication). From this perspective, categories of violence are not differentiated. The social concern is about violence itself, as aggressive behavior, which was almost exclusively considered male, as emphasized by the women’s rights movements of the period. In that perspective, prompted by natural selection and some human help to it, interpersonal violence would disappear following a long process of civilization that would develop individual self-control and a collective intolerance toward violence. Across the nineteenth century, social changes brought up considerations about population control and individuals’ power – the power of rational thought and selfcontrol as valued by Puritanism and capitalism – usually opposed to irrational beliefs and self-defeating behaviors, such as alcoholism and unnecessary violence. In this context, interpersonal violence was questioned about its role for the human species, in evolution, and in society. Violent behavior in domestic and interpersonal relationships did not raise public concern predominantly because of the harm done to individuals. The increasingly dominant value given to self-control explained the moralization of interpersonal violence, as much as the threat to social order and progress that violent behaviors constituted. Many authors linked these moral transformations to industrialization and the birth of a bourgeoisie, successfully supported by the values of Protestantism (e.g., Max Weber). These social transformations contributed to addressing the issue of violence in relation to concerns about social progress and to linking it to evolutionist theories. In this framework, violence is a symptom of the real danger, the degeneration of the species, which is the target of envisioned policies, such as eugenics. For the upper-class moral reformists of the period, it was also allegedly the fault of the working class, which would justify birth control policies aimed at the poor, as much as philanthropic methods to rescue through individual actions the victims of cruelty (Pleck 1987; Gordon 1988; Robertson 2005).

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In contrast, the emerging moral concern for cruelty against groups seen as vulnerable, such as animals, children, and women, can be connected to the growing legitimacy of the notion of individual self and related individual rights that should be granted on their behalf. In a parallel and somewhat paradoxical process, the recognition of individual subjectivity paired with an emphasis on the role of individual behaviors of members of society supported the development of biopolitics, such as policies that aimed to govern population growth and civilizational progress. The same process secured the privacy of the domestic space, while crime in the public space received increasing attention. The reinforcement of a division between the private and the public space explains the variable importance given to different types of interpersonal violence. Although violence in general became a sign of moral degeneration, and for some Darwinists also a sign of biological degeneration (Paul 2003; Browne 2016), interpersonal violence constituted a matter of public concern mostly when visible in the public sphere or when violating the private one. This differentiation led to legal actions against assaults perpetrated in the street or elsewhere outside the victim’s home, including rape when it happened in this context, whereas, even when regulations existed to sanction violence against women and children, violent acts taking place in the family were consistently left outside police and justice control (Gordon 1988).

Violence as Deviance At the beginning of the twentieth century, the violent behaviors prompting policies and studies were delinquency and crime. Public attention was brought to the youth and the criminal. Criminology and psychiatry represented the disciplines encountering “cases” of violence to study and analyze. In combination with the protection of privacy, this unsystematic way to collect data on violence supported the idea that sexual and domestic violence was relatively rare. Another phenomenon contributed to legitimate the expertise of the psychological sciences on interpersonal violence. From the end of the nineteenth century, the development of an administration providing services to and overseeing the growing population of urban areas required new knowledge on individual and collective behaviors. Social science and medicine gradually acquired an essential role in offering a matrix to understand human behaviors, and they were given the new position to advise on the proper course of actions. Social and psychological theories helped to build a new but rapidly rising group of professions – i.e., the nascent body of social workers, health professionals, and educators, which the sociologist Howard Becker (1963) would later call “moral entrepreneurs.” This new middle class of educated and mostly white professionals still fostered Christian values through their practices. But their moral enterprise found an apparently more neutral approach when resorting to scientific expertise, the new “regime of truth.” With the decline of social concern about domestic violence, which would be more and more linked to social and cultural attributes characterizing poor and immigrant families, the kind of interpersonal violence that raised public concern was violence

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in the public space. And though this category includes any interpersonal violence outside the domestic space, sex crimes were specifically the subject of social concern and would be the cause of specific policies and laws. During the 1930s, following the shocked reaction of the public about a series of sexual murder cases, a legislative reform introduced the term psychopath in the law (Freedman 2006, p. 128). These “psychopathy laws” incorporated norms of sexuality as conceived by nineteenth-century sexual science in Europe. The concept of psychopath started to be widely used. While its origins could be traced to European psychiatry, its definition was vague, and the use of the word encompassed a lot of behaviors. In the US media and public discourse, it gradually became a synonym for sex offender. The definition of sexual psychopathy borrowed notably from the work of the Austro-German psychiatrist Richard von Krafft-Ebing, who defined any nonreproductive sexual act as deviant (Freedman 2006). While the new regulations responded officially to the sex panic about sexual criminal acts, with a rhetoric dramatizing the danger threatening girls and women, the law could serve to target any “deviant” sexual behavior, such as consensual same-sex and heterosexual nonreproductive sex, if psychiatrists decided to diagnose it as psychopathy. The introduction of a psychiatric term in legal regulations and public policies illustrated the great credibility and power attributed during that period to psychiatry, as much as it contributed to building public trust in psychiatrists. The psychopathy laws failed to prevent sex crimes efficiently, but they corroborated the idea that rape and sexual violence were perpetrated by deviant psychopaths. The characterization of sex offenders as strangers hunting their prey in dark alleys reinforced the exceptionality attributed to rape, while this portrait of the perpetrators did not help victims raped by a relative to be heard and protected. At the beginning of the twentieth century, the examination of an individual’s psyche found a new tool when psychoanalysis arrived in the USA. Freudian theories presented a satisfactory framework for understanding the complex patterns of the human mind, but the predominance given to sexuality in psychoanalytical theories had mixed effects on cultural representations and norms. On one hand, opposing the social purity stance and its condemnation of sexual activity outside marriage and reproduction, psychoanalysis tried to normalize sexuality through a naturalization discourse and a theory of development including it as a necessary force to grow up and become a mature adult. On the other hand, it fostered a medical and psychological discourse on sexuality, which put sexual activities under professional scrutiny and social control, while producing categories of pathologies and abnormal behaviors. At the end of the 1940s, the report from a survey conducted by Alfred Kinsey (1948) demonstrated that American sexual behaviors would actually put most citizens in the situation of contravening the law and in particular the psychopathy laws. Kinsey’s research was used to advocate for more tolerant sexual legal norms on the ground that a liberation of cultural sexual norms was already in place. However, these norms were applied very differently to men and women. Psychoanalysts offered, for example, the notion of masochism, almost exclusively female in its clinical use, though not in theory, to explain the behavior of victims of rape, who

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would unconsciously seek to become victims (Akhtar 2017). This approach was spread to the point that rape victims were commonly accused of “secretly wanting it.” Although this theory was originally clearly developed in the case of sexual violence, the idea of willing victims was applied to victims of domestic violence as well. The theory of masochism obviously did not support the victims of sexual and/or domestic violence to escape violence nor to recover from it. It may however be apt to observe that before psychoanalysis, the women’s mental space was not an object of study, and no expert on violence showed much interest in how abused women felt. When women’s status slightly improved, an explanation of the behavior of a sensible human being had to be proposed. In the absence of consideration for gender power dynamics, the idea of masochism served to explain that abused women remained in situations of violence, or that they seemed to insufficiently defend themselves, including by remaining silent about their experience of violence. The “violence as deviance” approach was supported by a concern about criminality and conceptualized through a psychiatric perspective. Whether focused on the psychopathology of the aggressor or of the victim, it emphasized an individualistic conception of the origin of violence, paired therefore with an individual responsibility, although the legal responsibility of psychopaths has been disputed (Tosh 2011; Bourke 2007, p. 180–206). This legal and cultural evolution established a strong association between deviance and crime. The deviance perspective considered interpersonal violence as a legal and psychiatric issue requiring legal and psychiatric intervention on the involved individuals. The criminal dimension of interpersonal violence granted the legitimacy of public institutions to intervene in personal relationships. In twentieth-century US history, but also, increasingly, in other countries, security and crime became the most widely accepted reasons for the state to regulate behaviors and organizations. The legal scholar Jonathan Simon (2007) described this process as “governing through crime,” which was reinforced in the second half of the twentieth century by the new prominence given to victims and by the expansion of a culture of fear granting the state the right to protect citizen’s safety at any cost.

Violence as Conflict In the immediate postwar period (1950–1960), questions were raised about the risk of fascism in the USA. Through the work and hypotheses of social scientists, the nuclear family became the center of public attention (Staub 2011; Weinstein 2013). According to these researchers, because of its role as a matrix of citizens, the family could constitute a target of actions to prevent fascism, as much as social and racial inequalities. Poor, immigrant, and single mother families were however already the target of charities and public programs from the nineteenth century under the banner of child protection and assistance to the poor (Gordon 1988). As long as violence was

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associated with the degeneration of the human species, it justified a narrow focus on particular social groups. After the decline of the women’s movement supporting social purity and temperance, the emphasis on male violence against women and children disappeared. As in the case of violence against women, the concern for sexual abuse of children stressed assaults from strangers and covered up incest. The category of sexual delinquency supported furthermore this process of making invisible sexual abuse in the family by including both incest and sexual abuse from strangers. In addition, this perspective stressed that the victims were also sexually deviant and criminal. A shift from this social negative judgment on selected families to a trust by default to any family appeared during the Progressive Era and was reinforced during the Great Depression and World War II. Harsh economic realities of mass unemployment led the population to develop more sympathy for the financial difficulties of the involuntarily workless breadwinner. In a context where work was threatened and the world was an insecure place, individuals vested the nuclear family as a safe haven under their control (Gordon 1988). After World War II, the valorization of the traditional family did not decrease, but the search for the origins of fascism and hate pointed out the primary education system of any individual: their family. Experts who had already researched the source of racism expressed opinions about the need for democracy to raise mature and strong individuals. Psychiatry and psychology offered an expertise linking styles of communication and education with risks of psychopathology, delinquency, or undemocratic values, such as racism or fascism (Staub 2011). This context gave rise to family therapy. This type of psychotherapy has been theoretically supported by a specific theory of communication called cybernetics. Cybernetic approaches focused on signal and feedback loops. Family therapists observed family interactions and looked for pathological loops in order to change communication dynamics and prevent psychiatric diseases (e.g., schizophrenia), but also racism or juvenile delinquency. Family therapy, however, rarely addressed the problem of domestic violence directly, which would be criticized later by feminist mental health professionals (e.g., Osborne 1983). The family approach played nevertheless an important cultural part in supporting family values with the idea that families were at the heart of the making of citizens (Weinstein 2013). Concerning the issue of interpersonal violence, and more particularly domestic violence, family therapy also had a key but paradoxical effect: it encouraged looking into the family to find the causes of behavioral and social problems but tended to reframe violence as the product of miscommunication or conflict, denying power relations and working toward a resolution of the conflict that would maintain traditional family relationships. In the field of social work, especially in child protection services, it provided professionals with psychiatric categories for their social cases and with a new psychological framework on family violence. This psycho-educative approach to family violence reinforced the exclusion of interpersonal violence that happened in private from a political debate about power dynamics and legal regulations in favor of victims. This view on violence as a conflict displayed how the political and social treatment of interpersonal violence depended

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on how families were defined, conceived, and valued. It shows an evolutive relationship between the state and the administration of family life. And it illuminates the importance attributed to the family in the social production of individuals.

Violence as Oppression From the 1960s through the 1980s, social movements successfully broke with the previous psychological and legal approaches to violence. Activists insisted on associating violence with oppression. Power relations based on age, sex, class, and race differences were denounced as collective violence expressed in countless interpersonal violent interactions. The project of the 1960s and 1970s revolutionary movements extended far beyond the radical transformation of the political and economic organization of society, embracing a critical reappraisal of affective, intimate, and sexual relationships. Subjective distress was often seen as a sign of the social madness that was making individuals insane and hurting them. The effect of oppression on the self-urged profound social transformations. For some activists, any emancipation attempt should start with these issues, at the individual level first, as a sine qua non condition for collective emancipation. This idea is articulated, for example, by the preeminent feminist Gloria Steinem in the title of her book Revolution From Within (1992). This ambitious program of individual and collective emancipation has indeed been especially emphasized in the context of feminist movements. The famous feminist slogan “the personal is political” captured this standpoint as an important dimension of the second wave of feminism in North America and worldwide. The concern for the personal experience of oppression was related to the will to understand what the feminist scholar Colette Guillaumin (1992) called “the mental face of power relations.” The purpose was to underline how the oppression of women could be observed not only in their material conditions (i.e., their economic exploitation outside and inside the house, their limited or inexistent rights) but also in interpersonal relationships (including sexual assault, domestic violence, workplace harassment), all of which molded their whole life experience. The personal effects of oppression were embodied notably by rape and wife battering. In the context of the 1970s feminist movements, these two related issues were fought specifically. The anti-rape movement was the first to gain traction and momentum (Bevacqua 2000). After having won legal battles over abortion rights, the feminist movement made rape the next cause to free women’s body from patriarchal control. Radical feminists denounced sexual violence as a way to oppress women, if only by the fear that it could happen anywhere and anytime. Sexual violence was condemned as the most extreme and violent appropriation of women. The anti-rape movement offered both a radical determination with the goal of ending sexual violence and a factor of institutionalization and professionalization of feminist projects. At the beginning of the 1970s, feminist groups and collective started to realize the extent of women’s rape, in particular through collective and “consciousness-raising” moments when women shared their personal experiences.

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It became clear that victims of rape were not receiving adequate social, legal, and emotional support, including how the police and courts understood their experience, as much as how inadequate was the quality of care from health professionals. Feminist reframed the conceptualization of rape as the product of women’s oppression and viewed it as an intolerable attempt to maintain and enforce male control over their bodies and lives, which justified the development of solidarity between women, whether victims or not. They believed in the commonality of their experience of patriarchal violence. And they recognized the damage resulting from the experience of rape, which brought women to unite, in order to offer services for victims and to change society and relationships between men and women. These two missions generated tensions in the organization of the rape crisis centers, as much as in the movement itself (Schechter 1982; Akhtar 2017). The radical political project to transform interpersonal relationships and prevent violence through the emancipation of women and the formation of a new sexual and gender culture stumbled over the funding issues and institutional policies that arose from needed alliances to support services to victims. The social revolution that would be required to end violence involved a thorough critique of institutions, but also self-defense training for all women and the right to self-determination for the victims. But in order to improve the victims’ rights in court and in police proceedings, as in hospital and medical care, feminist activists had to work with these institutions and professionals and use their expertise in law, medicine, and psychiatry. By effectively raising public attention about rape and victims’ rights, feminist actions developed social awareness about sexual violence, but the effects were multiple and unpredicted. As Schechter (1982) put it: the funding from the state and other public institutions came with strings attached. Some rape crisis centers were asked to not support or stop supporting victims if they did not report the rape to the police, or when the court proceedings were over, which contradicted the aim that victims recovered control through self-determination. The anti-rape movement invented, however, a model of organizing and advocating that would inspire the battered women’s movement (Schechter 1982). With a similar dual project of helping victims of intimate partner violence and changing how society was understanding and handling domestic violence, the battered women’s movement was also related to the feminist movement and developed both services for victims and advocacy for legal reforms and more considerate treatments of victims in hospitals, administrations, courts, etc. It was also called the shelter movement because of one of the most important service offered: a shelter for the women running away from their violent homes (Schneider 2000). Both of these anti-violence movements had to address widespread myths about women victims of violence and the conditions in which violence happened. In particular, to transform the common perception of domestic violence and sexual violence as an individual and private matter, feminist activists adopted strategies to demonstrate the frequency of it, and the political dimension of what was at that time considered a personal experience (e.g., Ferree and Hess 1994). In addition to political actions, such as protests, lobbying, public testimony from victims of rape (called “speak-outs,” involving sometimes retaliations against the perpetrator), and

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support for the victims from volunteers (i.e., individual and collective space to speak about violence and find resources, legal help, healthcare, financial support, housing, etc.), feminist professionals and researchers, as well as professionals and researchers joining the cause late or seeing an opportunity in it, played a significant role in giving credit and expertise about violence against women (Rutherford 2011, 2017; Akhtar 2017; Cavalin 2016). They contributed to expose the prevalence of violence against women, to dispute the pathologization of victims, and to propose policies and healthcare adjusted to their needs. Through surveys documenting sexual and domestic violence and through alternative behavioral theories and studies grounded in a feminist understanding of women’s lives, mental health and social science researchers shaped a new view on interpersonal violence. Their perspective embraced a more realistic assessment of the power dynamics at stake in violent behaviors toward women and girls. It replaced causality and individual responsibility in a collective context and disputed the traditional justifications of violence against women. But after the radical momentum of the 1970s came the conservative backlash of the 1980s. The fight against violence as a fight against oppression lost its pull, while feminists, sexual minorities, and radicals were depicted as anti-family (Evans 2003). Ironically, conservative politicians arguing for traditional family values presented feminists with the opportunity to create an alliance concerning family violence. In addition to the evidence of the great prevalence of domestic violence – and more importantly than women’s oppression – harm done to women and children and the need to protect them were decisive arguments to make genderbased violence a public issue supported by a politically conservative majority. The study of the damaging effects of violence on women helped indeed to explain the perceived powerlessness of the victims and to justify an intervention from the public authorities. The consensus on specific policies about violence against women was therefore built around the need to improve the treatment of victims, notably in public institutions. This alliance was permitted by and reinforced the more traditional way to frame violence as a security issue. The emancipatory feminist perspective supporting self-determination and autonomy of victims was bent toward a more paternalistic approach to save vulnerable women, creating some tensions in the coalition about the goals and the priorities of federal funding (Delage 2017). The feminist position was complex because of two conflicting elements: advocating that violence against women was a public issue requiring state recognition of it, maybe through funding shelters and rape crisis centers, but certainly through legal reforms acknowledging the gravity of the crime and treating victims as victims and not as accomplices, and, at the same time, emphasizing the empowerment of women and their rights to self-determination, including to report violence or not or to stay or leave their home. The acknowledgment of violence against women as a public issue is without a doubt the result of feminist movements. Without exposing the power relations between men and women and therefore grasping the collective dynamic framing women’s relationships with men, interpersonal violence might still be only seen as an individual issue, necessitating only security policies. The political dimension of

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sexual and intimate partner violence contributed to convincing the public of the blamelessness of the victims. The anti-rape and battered women movements built themselves a supporting network and services for victims and women in general, notably with prevention initiatives, such as self-defense training (Bevacqua 2000). The important change that feminists enforced was how victims were considered: from psychological and sexual deviants to righteous victims deserving to be heard and supported.

Violence as Trauma Several authors have described how in the aftermaths of World War II, the concept of trauma gained a new status and recognition (e.g., Fassin and Rechtman 2007; Young 1995). The idea of psychological trauma has a long history of clinical and scientific debates about diverse conceptions and reformulations of it, from the concept of traumatic neurosis to post-traumatic stress disorder (PTSD) (Leys 2000). As it can be observed with the concept of violence, the notion of trauma and its discussion are related to specific and situated social events: for example, railway accidents and requests for compensations in the nineteenth century, the long-term effects of concentration camps on survivors, or recognition of soldiers’ postwar disabilities. The issue of responsibility has been at the heart of the twocentury long debates on the mental effects of traumatic events. Beyond the mechanism producing the psychological trauma, the disputed issue was to know who could prevent the traumatic experience and who would have to take care for the traumatized persons. The notion of psychic trauma appeared first in the 1860s writings of the British physician John Erichsen under the expression “trauma syndrome” in the context of railway accidents that had frightened passengers. The medical belief was that the shock provoked a material lesion, otherwise medically described as “trauma” (Leys 2000). The expression of “traumatic neurosis” proposed subsequently by Hermann Oppenheim (1889) still embraced this idea of a physical injury, an explicitly neurological one in this formulation. But the spread of the idea of trauma as a psychological wound resulting from tragic experiences owed a great deal to psychoanalysis and other psychodynamic approaches (Fassin and Rechtman 2007). Whether the psychological sources discussing trauma considered a biological substrate underlying the post-traumatic symptoms or not, the success of trauma certainly came from the effectiveness with which the concept summarized the distress caused by certain experiences. Beyond the medical disputes about its etiology or its clinical manifestations, trauma expresses the commonsense knowledge that human beings can be literally and metaphorically hit and hurt by unpredictable and damaging events. For this reason, as many scholars have noted, it is not surprising that it became associated with the rise of what Fassin and Rechtman (2009) called the “condition of victimhood,” which gained significant recognition since World War II. The inclusion of the post-traumatic stress disorder (PTSD) in the third edition of the Diagnostic

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and Statistical Manual of Mental Disorders (APA, 1980) confirmed the endorsement by US psychiatry of the new status given to victims. This occurrence is directly related to social movements exposing the rights of victims to be recognized as such, but also to internal changes in the American Psychiatric Association itself. In particular, its board and the DSM editorial committee expressed the will to distance themselves from psychoanalysis to defend the scientific credibility of psychiatry (Demazeux 2013; Decker 2013). One of the main lobbies for the listing of the PTSD in the DSM was US Armed Forces veterans, supported by some military psychiatrists and by the antiwar movement, which was eager to outline the damaging effects of war, even on soldiers (Young 1995; Fassin and Rechtman 2009). Feminists, especially feminist mental health professionals, played also their part in this historical event. The goal of both groups was to have the American Psychiatric Association acknowledge that the psychological distress of the victims of violent events was the product of these events, which could account for their reactions, without any individual predisposition. In other words, what was at stake was the admission by psychiatrists of the “innocence” of the victims, their blamelessness both regarding the traumatizing event and the distress that they experienced afterward. This perspective broke with the psychoanalytic concept of traumatic neurosis, which defended that post-traumatic symptoms appeared only in individuals who experienced an early trauma, the “original” trauma, that would be the real cause of their issues and vulnerability to additional traumatic experiences. The recognition of the PTSD diagnosis granted therefore trauma with two new intertwined features: a universal quality and a “normal” nature. The conceptualization of PTSD conveyed indeed the belief that it was a normal reaction to abnormal circumstances, supporting both the universality of what was considered traumatizing and of the effects of a traumatizing experience. The social fortune of the notion of trauma need to be explained however by a cultural change, and, as Fassin and Rechtman (2007, p. 276) wrote: the fact that trauma has become so pervasive a factor in our world is not the result of the successful dissemination of a concept elaborated in the scientific world of psychiatrists, and then exported into the social space of afflictions. It is rather the product of a new relationship to time and memory, to mourning and obligations, to misfortune and the misfortunate. The psychological concept, trauma, has enabled us to give a name to this relationship.

In her important book Trauma and Recovery, the psychiatrist Judith Herman (1992) illustrated this view perfectly when she argued that trauma is the defense of the abused against the perpetrators’ will to make their crimes forgotten. She considered that the power of the perpetrators, whether they are abusive partners or violent states, helped them to promote secrets and silence about their actions. From that perspective, the invasive and lively character of the post-traumatic symptoms constitutes a reminder of what has happened but is under pressure to be forgotten. It indicates the resistance of the person’s mind, working against the oblivion desired by the abuser.

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For these reasons, Herman (1992, p. 9) claimed that only social movements offered the conditions to study trauma systematically: Advances in the field occur only when they are supported by a political movement powerful enough to legitimate an alliance between investigators and patients and to counteract the ordinary social processes of silencing and denial. In the absence of strong political movements for human rights, the active process of bearing witness inevitably gives way to the active process of forgetting. Repression, dissociation, and denial are phenomena of social as well as individual consciousness.

In their fight to make violence against women a public issue, Herman and many other feminist mental health professionals supported indeed the study of what was seen as ineffable. They were sharing the perspective of the left, the antiracist and the feminist movements, which had embraced the idea of oppression as an experience of suffering. In this perspective, telling these stories was part of an empowering process to acknowledge the experience and the viewpoint of the oppressed. This contemporary view on trauma, which owes a great deal to feminist mental health professionals such as Herman, was crucial in expanding the scope of what is recognized as violence, including possibly any manifestation of oppression. Trauma offered also a practical middle ground to focus on: instead of arguing about power relations and politics, any side could acknowledge the effects of a violent event – as long as they matched the PTSD criteria. In the genealogy of interpersonal violence as a public health issue that this chapter draws, violence as trauma constitutes the middle stage between the political denunciation of violence as oppression and a sometimes reductionist health perspective on violence as harm. The work done by committed feminist scholars of explaining, documenting, and reframing violence against women has been conducted for other kind of interpersonal violence, but gender-based violence constituted the first kind of interpersonal violence observed from this social justice perspective and recognized by official organization such as the WHO. In particular, violence against women constituted the model to develop statistical surveys investigating the impact of violence on health. The demonstration of negative health consequences has been used as an argument for specific public policies and for the prevention of domestic violence. In conformity with the contemporary social attribution of a great demonstrative power to biology, funding was granted to research the neurobiological aspects of trauma (e.g., van der Kolk 2014), thus completing the process of showing evidence of trauma, its undeniable existence, as much as its undisputable harm. Bringing violence, as trauma, in the jurisdiction of health – or expanding the reach of health into the realm of power issues – created the conditions of its scientific study, but also of its regulation. Through the public health program that attempts to tackle interpersonal violence, a public mandate of surveillance was granted, and mechanisms allowing to collect more systematically data on violent events, such as mandatory reports, have helped to build a better view of the landscape of most kinds of interpersonal violence.

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Key Points • In the modern period, interpersonal violence has been denounced as a public issue on several occasions but framed and defined differently across time. • In the nineteenth century, industrialization and the development of a bourgeoisie sustained the influence of Puritan and Victorian morals condemning cruelty and concerned with social progress. Supported by ideals of rationality and science, which were notably embodied by Darwinism and population studies, the prevailing perspective on interpersonal violence viewed it as a sign of moral degeneration affecting specifically the working class and requiring population control through eugenics policies, as much as charity for the victims of cruelty. • Only in the twentieth century did interpersonal violence become an object of scientific study in itself. The growing legitimacy of the psychological sciences sustained the elaboration of psychological explanations of violent behavior. Psychiatry and criminology studied criminal behavior and qualified violence as deviance, which was caused by an individual psychopathology. Sex crimes in particular were understood as the actions of psychopaths and constituted the object of sex panics in the 1930s. The success of psychoanalysis and changing sexual norms reshaped expert views on sexual violence. The psychoanalytical conception of masochism appeared to explain rape, which was now seen as the product of the victims’ secret desire. • Other psychological approaches, blind to power relations, were offered to build a stronger nation in the postwar period. Experts pointed out the role of family as the matrix of individuals and proposed family therapy as a way to prevent delinquency and fascism. This perspective usually made domestic violence invisible through a communication theory framework that categorized violent episodes as conflict. • From the 1960s and 1970s, social movements, and in particular, feminist movements, showed the pervasiveness of interpersonal violence, first through testimonies and then through surveys documenting the frequency and severity of sexual, psychological, economic, and physical interpersonal violence toward girls and women. They succeeded to demonstrate its epidemic character and built services to help victims of rape and intimate partner violence. • These movements and the research that they inspired supported the recognition of the violence of oppression and of the psychological effects of violence. Through the notion of trauma and the introduction of the PTSD in the DSM, victims found a new status and started to be able to make legitimate claim about support and reparation. The focus on the health effects helped to build political alliances about violence against women and has become since then a model of efficient strategy to tackle interpersonal violence.

Summary and Conclusions This chapter presented a history of interpersonal violence as a genealogy of current social and scientific representations of interpersonal violence. After situating the social context in which the boundaries of violence are defined and contested, it

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described how a public health perspective embraced and framed the contemporary view on violence, which can be subsumed in the expression “violence as harm.” In order to grasp the historical and social formation of the current view of interpersonal violence, it proceeded then to depict how various conceptions of interpersonal violence occurred in the modern history. The presented series of approaches emphasized the process that linked them to social actions engaged in raising public awareness and concern about specific issues. In the nineteenth century, industrialization, population growth, and the ideal of progress conveyed a growing concern about poor and deviant individuals. Encouraged by biological science, the nineteenth-century view on innate character and biologically determined behavior still persists, as illustrated by the numerous and generously funded studies tracking biological markers and factors of aggressive behavior. The official maintenance of social order was gradually ensured by security policies. The study of criminalized deviance was entrusted to psychiatrists and criminologists, who had started to work on this subject with the same mind-set as the biologists: criminals were born criminals. Today, some researchers are still looking for the psychopathy genes. In the 1930s, the media frenzy about sex crimes called for women to fear their vulnerability to dangerous psychopaths, which would promote their protection, notably by staying in their “safe” homes. It is hard to not consider that the sex panics that took place during the interwar period did not constitute a call for “modern” women to respect the patriarchal order (Lancaster 2011, p. 37). The psychodynamic approaches that appeared in the USA in the twentieth century offered new views on delinquency, and besides the continuing task of identifying the irrecoverable offenders, they allowed psychiatrists to think about therapy efforts for the criminals. But their conception of gender roles did not help women. The gradual acceptation and use of the psychoanalytic notion of masochism for rape victims entertained the idea that victims were to blame, increased their lack of resources, and maintained the invisibility of ordinary sexual violence. Unfortunately, it cannot be said that this view has totally disappeared, despite the fact that it is not the current paradigm of mental health professionals with expertise on rape. Psychiatrists and psychologists, but also social workers, were keen to offer advice and therapy to immigrant and poor families, but the postwar development of family therapy shows how the war brought up general questions about democracy and its vulnerability to hate and fascism. Perhaps this provided justification for overlooking violence in the private sphere, while supporting family well-being as a means of preventing delinquency and potential overthrow of democratic states. Even if the first conception of family therapy did not pay much attention to domestic violence itself, this social concern sets the cultural and scientific basis for more public scrutiny into families, which would later support actions against child abuse (Ashby 1997). In the 1960s and 1970s, political movements and their perspective equating oppression and violence helped to reframe the relation between health and violence. Combined with cultural and institutional changes, they shaped a view of society as oppressive for most people, and this oppression was producing an unquantifiable

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number of victims. The spread and the growth of affected individuals represented the first condition to make it a public issue. But many other steps were required to make interpersonal violence a public health issue: building the blamelessness of victims, through political actions, but also through psychological explanations of their behavior and reaction; documenting the extent of the phenomenon through surveys; and reinforcing the legitimacy of the public issue by highlighting the negative health effects of violence. The framing of interpersonal violence as a health issue is not the result of a strategic conspiracy. It is the product of a series of factors: health professionals concerned about victims in a culture that, after the activism of social and feminist movements, started to think interpersonal violence – and notably sexual and domestic violence, and by extension emerging recognition of violence against myriad marginalized groups – was a serious issue that could be better handled; the legitimacy of the health argument to build consensus, through the perception of it as neutral, objective, and scientific; and, perhaps mainly, the expertise granted to medical and psychological sciences by political institutions and the public to address bad behaviors and find solutions to social issues (Herman 1995).

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Examining Interpersonal Violence from a Trauma-Informed and Human Rights Perspective Kelly Graves and Yasmin Gay

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What We Know About Various Forms of Interpersonal Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intimate Partner Violence and Sexual Assault . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Peer Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gang Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hate Crimes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Examining Interpersonal Violence from a Human Rights Framework . . . . . . . . . . . . . . . . . . . . . . . . . . Trauma-Informed Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Integrating the Trauma-Informed and Human Rights Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Toward a National Commitment to End Interpersonal Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. K. Graves (*) Kellin Foundation, Greensboro, NC, USA Y. Gay Wake Forest School of Medicine, Winston Salem, NC, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_204

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Abstract

The current chapter integrates a trauma-informed approach to address violence from a human rights perspective. Following a brief and necessarily selective review of what is known about the scope of various forms of interpersonal violence, the chapter examines interpersonal violence through a wide lens to reveal the intersections between the trauma-informed and human rights perspectives. The levels of interpersonal violence experienced around the world, combined with resultant trauma, suggest that a combined human rights-traumainformed approach to violence prevention and intervention may hold a key to advancing the human rights of protection, life, liberty, security, and health for individuals globally. The chapter makes the case that these two approaches complement each other in ways that can advance the field can lead to positive change for both public health and victim outcomes. Examples are offered. Keywords

Interpersonal violence · Trauma-informed care · Human rights perspective · Violence intervention · Violence prevention · Violence research

Introduction Interpersonal violence is a universal phenomenon that affects individuals of all cultural, ethnic, socioeconomic, and familial backgrounds (Ballan et al. 2014). Yet, living free from interpersonal violence should be a basic human right. Because violence is a human rights violation (Kelly 2006), understanding how to address interpersonal violence from a human rights perspective provides a useful framework for policy makers, practitioners, and researchers. Likewise, all forms of interpersonal violence are potentially traumatic, resulting in short- and long-term negative consequences for the victims, their families, and communities. According to the WHO (1996), violence is defined as the “intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.” Although this handbook focuses on interpersonal violence, it is important to note that the WHO recognizes that violence is multifaceted and experienced in various forms, including self-directed violence and collective violence, as well as interpersonal violence (Rutherford et al. 2007). Whereas self-directed violence is indicative of an individual’s actions (i.e., suicidal thoughts, actions, and behaviors that reflects self-harm), collective violence is indicative of a group’s actions (i.e., use of violence by people who identify themselves as members of a group against another group of individuals to achieve political, economic, or social objectives). Thus, the concept of interpersonal violence serves as an overarching umbrella that includes acts of violence and intimidation that occurs between family members, intimate partners,

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acquaintances, or strangers (Rutherford et al. 2007; Zwi et al. 2002). Regardless of the type of interpersonal violence, the dimensions of the violence perpetration can be similar and include physical violence, sexual violence, psychological violence, and deprivation and/or neglect (Krug et al. 2002). The current chapter will review how using a trauma-informed approach to address violence from a human rights perspective can lead to positive change for both public health and victim outcomes. We first present a brief and necessarily selective review of what we know about the scope of various forms of interpersonal violence. With these national and international statistics in mind, we then examine interpersonal violence with a wider lens to reveal the intersections between the trauma-informed and human rights perspectives. Although the specific contextual factors across these types of violence differ, they share intersectionalities that unify them – people who live with widespread interpersonal violence and trauma, as victims and as bystanders, cannot fully enjoy their rights to life, liberty, security of person, and health (Phinney and de Hovre 2006). The levels of interpersonal violence experienced around the world, combined with resultant trauma, suggest that a trauma-informed approach to violence prevention and intervention may hold a key to advancing the human rights of protection, life, liberty, security, and health for individuals globally (Phinney and de Hovre 2006). Thus, subsequent sections of this chapter, we make the case that these two approaches complement each other in ways that can advance the field. Examples are offered.

What We Know About Various Forms of Interpersonal Violence Child Abuse Children are one of the most vulnerable populations when it comes to interpersonal violence. For example, the Children’s Exposure to Violence study (Finkelhor et al. 2009) indicated that more than 60% of children in the USA were exposed to violence, either directly or indirectly, and that poly-victimization was common, with more than 33% of children experiencing two or more direct victimizations during the past year. Using a wider time frame of “ever been victimized” as an anchor, Finkelhor et al. (2007) found that 71% of children surveyed through a national sample experienced at least one form of victimization, with 69% of those indicating more than one type of victimization. Worldwide, approximately 25% of children experience physical abuse and every year at least 41,000 children under the age of 15 are victims of homicide across the globe (World Health Organization 2017a). Perhaps one of the most referenced studies that links trauma, violence, and negative outcomes is the Adverse Childhood Experiences (ACE) study, which documented that adults who were exposed as children to six or more traumatic events, including violence exposures such as physical abuse, sexual abuse, verbal abuse, have a 20-year shorter life span (Felitti et al. 1998). The ACE researchers found a direct linear relationship between the number of ACE’s endorsed and a full

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range of negative impacts, including mental (increased risk of depression, anxiety, bipolar disorder, etc.), physical outcomes (increased risk of stroke, diabetes, heart disease, etc.), behavioral outcomes (increased risk of risky sexual behaviors, substance use, etc.), and life course outcomes (increased risk of divorce, job transitions, etc.). For a full review of the findings of the ACE study, see Felitti et al. (1998) and the Centers for Disease Control and Prevention webpage that includes all of the ACES instruments and latest research (https://www.cdc.gov/violenceprevention/ childabuseandneglect/acestudy/index.html). Additional research examining an expansion of the ACE questionnaire for various diverse populations is also in progress and gaining headway (see http://www.philadelphiaaces.org/). For example, research conducted by Cronholm et al. (2015) found that elements such as race, gender, and poverty left certain demographic groups more prone to higher risk for expanded adverse childhood experiences.

Intimate Partner Violence and Sexual Assault In the United States (US), it is estimated that 25–35.6% of adult women and 7.6–28.5% of adult men experience intimate partner violence in their lifetime (Black et al. 2011; Tjaden and Thoennes 2000). In fact, the US Department of Justice (DOJ 2005) reported that between 1998 and 2002 11% or 3.5 million people experienced violence and 49% of that experienced violence by their spouse. Sexual assault also is common within intimate and acquaintance relationships, with nearly one in 10 women in the USA reporting that they have been raped by an intimate partner in their lifetime (NSVRC 2015). Sexual assault can also occur outside of these existing relationships, with lifetime estimates of rape in the USA being one in five women and one in 71 men (NSVRC 2015). Global estimates indicate that about 1 in 3 (35%) of women have experienced physical or sexual assault in their lifetime (WHO 2017).

Older Adults Another vulnerable population negatively impacted by violence, including family violence and sexual assault, is the elderly. The maltreatment and abuse of elders is prevalent, but the magnitude is unknown due to underreporting. Elder abuse is defined in many ways. Rosenberg et al. (2006) define elder abuse as the mistreatment of older people, generally those older than age 60 or 65 in the home or in an institutional setting. According to Wolfe et al. (2003), elder abuse is a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person. Rutherford and colleagues (2006) noted that “elder abuse may be an act of commission or omission and may be intentional or unintentional” (p. 678). Like abuse in other populations, elder abuse can be experienced in diverse ways that may include physical, psychological, financial, sexual abuse or neglect. Lachs and Pillemer (2004) noted that abuse of elderly people can take place in various environments,

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including their homes, hospitals, assisted living arrangements, and nursing homes. Hardin and Khan-Hudson (2005) suggests that the largest group of elder abusers appear to be family members and caretakers. In fact, Laumann et al. (2008) found that among the elderly, the most frequently reported form of abuse was verbal mistreatment (9%) enacted by members of their family. While elderly abuse is perceived diversely among cultures, for example, among the Chinese, psychological abuse which includes verbal and emotional abuse was perceived to be more serious than other forms of abuse (Chang and Dong 2014).

Community Violence While family violence occurs in the context of an ongoing relationship, community violence refers to interpersonal violence in the community that is not perpetrated by a family member and is intended to cause harm (Guerra and Dierkhising 2011). It includes sexual assaults by strangers and violence that occurs in settings such as residential care facilities, jails, and workplaces (Rosenberg et al. 2006). Community violence is a major issue that reflects experiences inclusive of violence that is perpetrated by acquaintances (nonrelatives or peers, but not intimate partners) and/ or strangers. Violence perpetrated by individuals who are known to the victim is a common occurrence. According to the Rape, Abuse, and Incest National Network (2015), 45% of rapes are committed by an acquaintance, indicating that acquaintance rape and other types of sexual assault (e.g., sexual coercion, unwanted sexual contact) by nonstrangers were far more prevalent than anticipated. According to the Bureau of Justice Statistics (2008), in the USA, 65% of all rapes and/or sexual assaults occur between nonstrangers, with 46% occurring between individuals who know each other well (not including relatives) and another 13.5% occurring between casual acquaintances. According to the US DOJ (2015), 28% of rapes are committed by strangers. Emergency room data indicate that acquaintance assaults are the largest category of sexual assault type, followed by stranger assaults (Logan et al. 2007). In contrast, with stranger violence, the victim does not know any of the perpetrators (Mattinson 2001). According to data provided by the US DOJ, males (9.5 per 1000 males) experienced violent victimizations by strangers at nearly twice the rate of females (4.7 per 1000 females) (Harrell 2012). In fact, the group of people most frequently victimized by strangers is young males aged 15–24, followed by men between the ages of 25 and 34 (Sherley 2002).

Peer Violence Peer aggression and bullying, especially among peers and adolescents, is another element of interpersonal violence. According to the WHO (2002), bullying is the intentional use of physical and psychological force or power, threatened or actual, against oneself, another person, a group, or community that either results in injury, death, psychological harm, mal-development, or deprivation. Acts of bullying and

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peer aggression may include acts of hitting, punching, destruction of property, teasing, taunting, and/or threatening others (Kristensen and Smith 2003; Slone and Smith 2008). Research by Nansel, Overpeck, Pilla, Ruan,Simons-Morton, and Scheidt (2001) found that in the USA bullying and aggression was more prevalent among males than females, and more frequently among middle school aged youth than high school aged youth. The National Institute of Child Health and Human Development (2001) estimated that 5.7 million American children in grades 6–10 have experienced or witnessed bullying and one in four children have been victimized by their peer or classmate every month. The phenomenon of bullying and peer aggression among children and adolescents is a concerning intersection of interpersonal violence that has led to detrimental outcomes, such as bully-cide (suicide occurring as a result of bullying), school shootings, and other elements of school violence (Phillips 2007).

Gang Violence Gang-related violence is a significant problem and a distinct form of interpersonal violence and aggression. In the USA alone, it is estimated that there are approximately 30,000 gangs and 850,000 gang members, who are generally between the ages of 12–24 (National Gang Center 2018b). Gang participation and engagement is diverse in nature as it includes actions that may include drug sales, drive by shootings, assault, and/or homicide. These activities involve both expressive and instrumental criminal actions and violence that negatively affect members of diverse communities. According to Jennings-Bey et al. (2015), repeatedly witnessing gang homicides enculturates children into violence, which may lead them to continue the cycle.

Hate Crimes Hate crimes are another manifestation of interpersonal violence. Hate crimes are perpetuated based on the victims’ race, gender ethnicity, national origin, religion, sexual orientation, or disability (Plumm et al. 2014). Within the USA, residents experience an average of 250,000 hate crime victimizations each year between 2004 and 2015 (US DOJ 2017). Those crimes include rape, sexual assault, robbery, aggravated and simple assault, robbery, larceny, and vandalism. The interpersonal elements victims of hate crimes experience offer lasting and traumatizing effects that often impact their worldview.

Examining Interpersonal Violence from a Human Rights Framework Addressing the concept of interpersonal violence is not a new phenomenon for the human rights community. Human rights law has been used to support the pervasive belief that violence is an intrinsic part of human existence (Phinney and

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de Hovre 2006). Violence that is perpetrated against and experienced by anyone is a human rights violation to all (Kelly 2006) and encompasses diverse types of violence across the lifespan from child abuse to elder abuse. As the brief review of types of violence in the previous sections shows, violence has many manifestations, including psychological, physical, and sexual (see Cook and Parrott 2009 for a taxonomy of violence). All forms of violent acts both violate human rights and arise from inadequate fulfillment of human rights (Phinney and de Hovre 2006). Simultaneously, interpersonal violence is a public health concern and is commonly associated with numerous long-term health effects, both physical and mental, and results in increased use of health care services (Elliot 2003). In every nation, interpersonal violence heavily burdens health and social service resources, causes social disruption, and creates obstacles to peace, health, and human well-being (Phinney and de Hovre 2006). It is estimated that interpersonal violence kills more than 1.6 million people each year, with the number of nonfatal violent occurrences being almost unquantifiable given the sheer volume of occurrences (Rosenberg et al. 2006). Interpersonal violence has lasting effects on myriad aspects of the human existence and can manifest itself in a variety of ways both immediately and over the lifespan. For example, the family violence umbrella includes any form of maltreatment – including physical, sexual, neglect, or emotional – perpetrated or witnessed by one or more members of a family and/or intimate relationship upon one or more other members of that family or relationship (Murray and Graves 2013). In these forms of violence, the interpersonal experience is connected to individuals with whom the victims had an ongoing relationship.

Trauma-Informed Perspective From a lifespan perspective, research continues to document the strong links between trauma exposure in childhood and a wide variety of negative health outcomes throughout adulthood. Trauma has been defined as “an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being” (SAMHSA 2014, p. 7). Traumatic responses can manifest differently based on many factors (i.e., age, gender, culture, etc.), but generally includes symptoms such as hypervigilance, flashbacks, avoidance of situations or people that bring back memories of the trauma, sleep disturbances, guilt, anhedonia, irritability, anxiety or depressed mood. Trauma, by virtue of trauma itself, can create vulnerability. However, there are some populations that are particularly vulnerable to trauma and its impacts such as children, individuals with disabilities, and immigrant and refugee populations to name a few (see Evans and Graves 2018, for a deeper review). Thus, not only does trauma particularly impact vulnerable populations, but in turn, exposure to trauma can create additional vulnerability (Shivayogi 2013). This is important to address from both a social justice and

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human rights perspective given that research tells us that the cumulative effects of trauma and disadvantage can lead to health disparities and other negative life outcomes (Hsia and Shen 2011). Given the different manifestations of traumatic stress, the trauma-informed rule of “first do no harm” demands that both researchers and practitioners ensure that the delivery of services does not further violate those who have experienced interpersonal violence. Researchers and practitioners should be acutely aware of the core principles of trauma-informed care. Trauma-informed responses to care are often described in a mnemonic of the “4 R’s” – realize, recognize, respond, and resist. Operationally speaking, a “program, organization, or system that is trauma informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; responds by fully integrating knowledge about trauma into policies, procedures, and practices; and seeks to actively resist re-traumatization” (SAMHSA 2014, p. 9). Trauma-informed care is a philosophical framework that is based on the recognition that many behaviors and responses expressed by survivors are directly related to traumatic experiences (Substance Abuse and Mental Health Services Administration [SAMHSA] 2014). Trauma-informed care is not a specific model of treatment, but rather, the creation of an environment that is supportive and wrapped around awareness that survivors and their behaviors are viewed differently by staff (and the institutions and clinics within which they work) who understand that behaviors are expressions of traumatic responses (Jennings 2004). In trauma-informed approaches, there is an emphasis on creating a safe environment and on building skills and empowerment, rather than on pure symptom management. A trauma-informed environment focuses on understanding what has happened to the person rather than what is wrong with the person, which is one of the hallmark elements established by Herman (1992). In this way, a trauma-informed approach provides a useful framework to also address violence from a human rights perspective.

Integrating the Trauma-Informed and Human Rights Perspectives Trauma-informed approaches share many similar values with a human rights perspective, including a focus on safety, collaboration, empowerment, choice, and trust. These principles are universal both in a trauma-informed setting and from a human rights standpoint. That being said, the ways in which these principles manifest may “look” different depending upon the socio-cultural context and individual values of the person in order to ensure cultural sensitivity. But similar to a human rights approach, a trauma-informed approach believes that safety, collaboration, empowerment, choice, and trust are inherent rights, regardless of a person’s nationality, sex, national or ethnic origin, religion, race, culture, language, sexual orientation, or other status. And also similar to a human rights perspective, these tenants of a trauma informed approach are interrelated, interdependent, and indivisible.

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There are many strategies that can be put into place using a trauma-informed perspective that can help ensure that living violence-free is a human right. Such strategies can be organized around the four R’s framework of being trauma-informed discussed above. For example, under the “realize” component, strategies for forward movement might include increasing awareness and understanding about the impact of violence and trauma, as well as a greater understanding of the effective trauma assessment strategies and interventions that can help those impacted cope and recover. This might include providing trauma focused education and skill building trainings to all researchers, practitioners, and staff. Systems should educate and train their staff on a variety of topics on a regular schedule. These topics should include issues such as defining trauma, the impact of trauma, the impact trauma has on childhood development, how cultures understand and respond to trauma development, trauma-sensitive assessment and research, and the implications of working with trauma survivors. Under the “recognize” component, individuals and organizations can focus on increasing their capacity (and the capacity of their communities) to identify signs of violence early and provide the proper resources to ameliorate the impacts of violence on victims. Once staff have been educated on trauma-informed care, there is a need to learn how to apply the education they have learned with those that they work with. For example, when talking with victims, the staff should respond in ways that the victim feels safe instead of in a way that is punitive and disrespectful. Under the “respond” component, strategies might include intentional focus on creating more coordination and communication across systems (Murray et al. 2016). Proper assessments are key so that staff know the right questions to ask and how the information gathered will be used so as to help the victim feel the most safe and comfortable through the process (Guarino et al. 2009). And, through these strategies, there is an inherent focus on addressing the “resist” component in that evidencebased treatments and cross-systems collaboration can help to minimize the risk of reexposing the survivor to additional trauma and encourage consistent traumainformed services throughout treatment. Trauma-informed systems should also leverage information that is available from state, national, and international expert groups such as the National Child Traumatic Stress Network (NCTSN; www.nctsn. org) as these groups serve as repositories for the latest evidence-based approaches to violence and trauma (Ko et al. 2008). By successfully integrating these components, trauma-informed care approaches provide a framework to deliver a higher and more cohesive level of service to those impacted by interpersonal violence. Creation of trauma-informed systems is desperately needed for victims as well as those who work for these agencies and systems. Coordination across systems helps not only the trauma survivor, but can also help minimize duplicate or unbeneficial services and increase the chances of the victim successfully recovering from their traumatic event (Graves et al. 2018). If systems continue to work independently of each other without a coordinated approach, the victims of interpersonal violence could experience inadequate, prolonged services which could lead to additional trauma. Thus, by being trauma-informed, there is a greater likelihood of not only successful outcomes for survivors (Ko et al. 2008; NCTSN 2014), but also an inherent growth in maximizing human rights and social justice.

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As trauma-informed systems begin to develop partnerships within their community, trauma-informed communities will begin to emerge. Trauma-informed communities include collaborative efforts among multidisciplinary practices that provide trauma-focused services, interventions, and trainings that are research based. Trauma-informed communities better serve those who have experienced trauma through their collective efforts and coordinated approaches to trauma-informed care. Such collaboration helps to ensure a public health approach that recognizes that addressing interpersonal violence is not the responsibility of any one person or system, but a shared responsibility by everyone in the community.

Toward a National Commitment to End Interpersonal Violence Given the complexities of interpersonal violence, and that violence is multidetermined and embedded within the social and cultural fabric of communities, developing a unified national plan can be a daunting task. However, the importance of developing such a plan cannot be overstated for the safety of the individual, the family unit, and the community at large. This plan will need to be one that incorporates violence prevention and intervention strategies that are trauma informed, collaborative, coordinated, and evidence-based. Considering interpersonal violence as a human rights violation as well as a catalyst to posttraumatic stress responses that can negatively impact developmental trajectories provides a new way of thinking about how to best intervene from both a practical and research perspective. When examining the impacts of interpersonal violence in this way, one will be forced to consider not only the social and emotional consequences of violence, but also the biological and brain-level changes that can result from exposure to violence. This mind-shift creates a new lens to consider biological approaches that are sensitive to the ways that the brain has been impacted in terms of both its form and function. From this perspective, the principles of trauma-informed care, such as safety and trust-building, are foundational concepts that should undergird any interactions with violence survivors. When examining interpersonal violence research and practice using this trauma-informed lens from a human rights perspective, a greater focus can be placed on recognizing the multiple intersections of violence leading to a dramatically improved response to how we address it across communities. For more in-depth information about the National Plan to End Interpersonal Violence Across the Lifespan, please refer to the specific chapter herein.

Key Points • Interpersonal violence affects all individuals of all cultural, ethnic, socioeconomic, and familiar backgrounds (Ballan et al. 2014). • Interpersonal violence is a major public health concern (Elliot 2003) and a human rights violation (Kelly 2006).

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• Interpersonal violence has many intersections with individual, family, and community-level factors that can alter the impacts of violence exposure over time. • A paradigm shift is needed that focuses on creating violence prevention and violence intervention strategies that are trauma informed and considers the complex ways that interpersonal violence impacts daily functioning and well-being. • Trauma-informed approaches to violence prevention and intervention may hold a key to advancing the human rights of protection, life, liberty, security, and health for individuals globally (Phinney and de Hovre 2006). • Trauma-informed care is a philosophical framework that is based on the recognition that many behaviors and responses expressed by survivors are directly related to traumatic experiences (SAMHSA 2014). • Given the different manifestations of traumatic stress, the rule of “first do no harm” demands that both researchers and practitioners ensure that the delivery of services does not further violate those that have experienced interpersonal violence. • Consistent with a human rights approach, a trauma-informed approach believes that safety, collaboration, empowerment, choice, and trust are inherent rights, regardless of a person’s nationality, sex, national or ethnic origin, religion, race, culture, language, sexual orientation, or other status, and that these tenents are interrelated, interdependent, and indivisible. • Interpersonal violence research and practice would benefit from using the essential elements of a trauma-informed approach that focus on restoring human rights in their research protocols and practices.

Summary and Conclusion Developing a global commitment to end interpersonal violence requires a coordinated approach. Multiple service sectors, protective services, victim advocates, mental health providers, substance use providers, faith communities, judicial systems, universities, business leaders, law enforcement, local nonprofits, and many other partners must work together to create a synergy that can point toward addressing interpersonal violence from both a prevention and intervention perspective. A key foundational element is for all stakeholders to understand the tenets of a trauma-informed approach to both research and practice and to understand that violence is a violation of human rights that has many intersections with individual, family, and community factors. With the key tenets of trauma-informed practice as guideline principles, research and practice in the area of interpersonal violence can be more sensitive, engaging, and effective.

Cross-References ▶ Adverse Childhood Experiences: Past, Present, and Future ▶ A National Plan to End Interpersonal Violence Across the Lifespan

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▶ Correlations Among Childhood Abuse and Family Violence, Prevention, Assessment, and Treatment from a Trauma-Focused Perspective ▶ Intersectionality ▶ Intimate Partner Violence and Intimate Partner Stalking ▶ Lifespan and Intergenerational Promotive and Protective Factors Against the Transmission of Interpersonal Violence in Diverse Families ▶ Overview of Child Maltreatment ▶ Treatment of Post-traumatic Stress Disorder in Survivors of Intimate Partner Violence

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Adverse Childhood Experiences: Past, Present, and Future Tamara A. Hamai and Vincent J. Felitti

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The History of ACEs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevalence of ACEs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cumulative, Dose-Response Effect of ACEs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ACEs and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ACEs and Substance Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ACEs and Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ACEs and Behavioral Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ACEs and Other Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scope of Adverse Experiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Different Approaches to Models of ACEs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Causal Pathways from ACEs to Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chronic Overactivation of Hypothalamic-Pituitary-Adrenal (HPA) Axis . . . . . . . . . . . . . . . . . . DNA Methylation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alteration of Immune and Inflammatory Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alterations to Brain Structure and Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alterations to Emotion and Behavior Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intergenerational Epigenetic Effects of ACEs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Protective Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. T. A. Hamai (*) Hamai Consulting, Palo Alto, CA, USA e-mail: [email protected] V. J. Felitti Kaiser Permanente Medical Care Program, San Diego, CA, USA © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_305

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Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Abstract

The introduction of adverse childhood experiences (ACEs) with the original ACE Study (Felitti et al., Am J Prev Med 14:245–258, 1998) transformed how people thought and worked across multiple disciplines. After more than 30,000 citations in research publications (CDC, Adverse childhood experiences journal articles by topic area. Retrieved from https://www.cdc.gov/violenceprevention/childabu seandneglect/acestudy/journal.html, 2019), researchers and practitioners have increasingly acknowledged and addressed the importance of children’s early traumatic experiences throughout the lifespan. ACEs have a cumulative, doseresponse effect on a wide range of health, mental health, behavioral, cognitive, social, and biomedical outcomes in later childhood and adulthood, increasing as the number of categories of ACEs increases. This chapter summarizes the historical and current understanding of ACEs and the multiple pathways by which they lead to physical, psychological, behavioral, and intergenerational harm. Despite attracting worldwide attention to childhood trauma over the past 22 years, ACE research has yet to be adopted in schools, policing, judicial systems, legislation, human services, and medical practice. Adopting universal trauma screening and primary prevention through work with parents, providers, educators, and other community members on how to effectively interact with and support children is critical in limiting the damage of ACEs and preventing future ACEs from occurring. Keywords

Adverse childhood experiences · Adversity · Mental health · Health · Disease · Chronic disease · Risk factors · Protective factors · Prevention · Early intervention

Introduction For many years, research has documented the prevalence and effects of childhood abuse, risk, and adversity. In 1998, multiple disciplines evolved with the introduction of adverse childhood experiences (ACEs) research. As of 2017, the ACE Study has been cited 32,119 times in 150 journals (CDC 2019). Historically, studies focused on one type of abuse or risk at a time, with limited exploration of cooccurrence of different types of abuse or risk. Most children who experience abuse have experienced multiple types (Edwards et al. 2003). ACEs cause feelings of stress, fear, and helplessness that overwhelm children’s coping mechanisms (Hinojosa et al. 2019). The effect is cumulative (Larkin et al. 2014); the likelihood of negative outcomes in later childhood and adulthood increases as the number of

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categories of ACEs increases. Understanding ACEs moved research from individual risk toward cumulative risk and its impact, as well as highlighted the critical importance of early childhood experiences on well-being throughout the lifespan. This chapter summarizes the history of research on ACEs and the current understanding of the definition and consequences of ACEs. Next, it describes the multiple pathways by which ACEs cause their many physical, psychological, behavioral, and intergenerational consequences. It concludes with several implications for the future of ACEs in research and the real world of prevention and treatment.

The History of ACEs The original ACE Study (Felitti et al. 1998) was groundbreaking in terms of the size, standardization, and comprehensiveness of its data set, as well as its results. The ACE Study began in the mid-1990s at Kaiser Permanente’s Department of Preventive Medicine in San Diego as an outgrowth of the Department’s Obesity Program. Counterintuitively, the patients who were most successful in the Obesity Program, which introduced a new technique of supplemented absolute fasting, were most likely to drop out. Experiencing weight loss of up to 300 pounds per year was commonly frightening to patients. Exploration of this surprising pattern led to the discovery that major obesity was often an unconscious protective response to unrecognized ACEs, particularly childhood sexual abuse (Werner and Smith 2001). A comprehensive medical evaluation, called the Health Appraisal Program, yielded data about the prevalence in a general population of these adverse experiences during the first 18 years of life and how they relate to later health outcomes. Over two visits, 17,337 of the 26,000 eligible adult patients (predominantly White and college-educated with an average age of 57 and health insurance) completed a medical history questionnaire, ACE Questionnaire, biomedical tests and measurements (e.g., urinalysis, audiogram, chest radiograph or mammogram, blood draw, electrocardiogram), and a detailed physical examination (including fundoscopy, rectal and pelvic exams, and neurological exam; Felitti et al. 1998; Felitti 2019)). The Health Appraisal Program successfully achieved its goal of reducing medical utilization, with reductions of 11% in emergency room visits and 35% in outpatient visits in the subsequent year, and created a standardized, comprehensive medical database, used for the ACE Study (Felitti 2019). Felitti and his colleagues (Felitti et al. 1998) assessed the relationship between ACEs with adult health behaviors and risk for negative health outcomes using the ACE Questionnaire, which measured the ten most common ACEs in the Obesity Program’s participant population. These ACEs questions were adapted from published tools (Felitti et al. 1998), including the Conflict Tactics Scale (Straus and Gelles 1990), Wyatt’s measure of sexual abuse (Wyatt 1985), 1988 National Health Interview Survey (National Center for Health Statistics 1991), Behavioral Risk Factor Surveys (Siegel et al. 1992), Third National Health and Nutrition Examination Survey (Crespo et al. 1996), and Diagnostic Interview Schedule (Robins et al. 1981). The ACEs measured were three types of childhood abuse

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(physical, sexual, and emotional), two types of neglect (physical and emotional), and five categories of household dysfunction (parental death, separation/divorce/abandonment, witnessing domestic violence, household member incarceration, household mental illness, and household substance abuse). Patients reported which ACEs they experienced, and the authors calculated a total ACE score by adding the number of categories of ACEs for each patient (Felitti et al. 1998).

Prevalence of ACEs The first key finding from the original ACE Study is that ACEs were unexpectedly common and exposure to one ACE dramatically increased the chances of exposure to additional ACEs (Felitti et al. 1998). Of the 26,000 eligible Kaiser members, 17,337 participants had complete health and ACE data (Felitti et al. 1998). Sixty-three percent of the sample experienced at least one ACE. Of the people exposed to any single ACE, the probability of exposure to any additional ACE was between 65% and 93%. Subsequent studies throughout the United States have supported this finding. Prevalence rates vary but remain relatively high, and studies consistently find that exposure to one ACE increases the odds of exposure to additional ACEs (e.g., Dube et al. 2003). Kaiser Permanente Northern California observed a lower prevalence for a sample of pregnant patients, with 46% reporting 1 or more ACEs and 18% reporting 3 or more ACEs (Young-Wolff et al. 2019). Meta-analyses documented prevalence in the United States of 1 or more ACEs ranging from 33% to 88% and 4 or more ACEs ranging from 1% to 38% (Hughes et al. 2017) and lower prevalence when including all of North America (23.4% with at least one ACE, 35.05% with two or more ACEs (Bellis et al. 2019)). Large national or multistate studies tend to observe prevalence between 59% and 77% (e.g., Appleton et al. 2019; Brumley et al. 2017; Gilbert et al. 2010; Radcliff et al. 2019); however, studies using the 2011–2012 National Survey of Children’s Health data yield lower prevalence rates with ACE scores of 1 or higher (23.3% (Cprek et al. 2019), 53% (Heard-Garris et al. 2018), 44.2% (Hinojosa et al. 2019)). Individual studies have observed higher prevalence as well (e.g., 85% with one or more ACE (Mersky and Janczewski 2018)). Although ACEs are common across all races/ethnicities, geographies, genders, socioeconomic groups, sexual orientations, and levels of health care needs, certain populations in the United States may have higher prevalence of ACEs. Prevalence and average number of ACEs are higher for Black, Hispanic/Latinx, indigenous, Asian, and multiracial Americans than for White Americans (e.g., Felitti et al. 1998; Gilbert et al. 2010; Stern and Thayer 2019). Each racial/ethnic group may be more vulnerable to specific ACEs. For example, Black and Hispanic/Latinx Americans tend to have greater rates of household dysfunction, and Hispanic/Latinx Americans tend to have greater rates of physical abuse and household alcohol use than White Americans. Many Middle Eastern Americans report being judged unfairly due to their race/ethnicity (77% (Wang et al. 2019)).

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Some researchers have questioned the relevance of ACEs given most studies were conducted in the United States and other industrialized countries (Chang et al. 2019); however, prevalence studies in other countries yield rates similar to rates in the United States. In Europe, a meta-analysis observed overall prevalence of 23.5% with one or more ACEs (Bellis et al. 2019); however, there may be country-level variation. Samples from Wales (48.5% (Bellis et al. 2018)) and Scotland (57% (Blair et al. 2019)) yielded lower prevalence of ACEs than samples from Montenegro (62.3% (Brajovic et al. 2019)) and Germany (73.8% (Wiehn et al. 2018)). Prevalence in Asian samples tends to be higher than European samples. To illustrate, studies at universities in China, Hong Kong, Taiwan, and Japan observed 44.8% (Ji and Wang 2018) and 66.3% (Ho et al. 2019) with at least one ACE. In South Australia, exposure to any ACE increased the chance of exposure to additional ACEs, increasing with each additional type (Malvaso et al. 2019). There is also emerging evidence that ACEs may be more common in less industrialized areas of the world. A study in rural communities in China found 66.2% of respondents reported one or more ACEs. In South Africa, 90% of participants in a cross-sectional study had one or more ACEs, and 15% had six or more ACEs. Many, but not all, studies found that women experience more ACEs than men. When limiting the original ACE Study data to only women who had been pregnant, prevalence of one or more ACEs was 66%, as compared to 63% with the full sample (Dietz et al. 1999). Women report higher ACE scores than men in several other studies (Gilbert et al. 2010; Nurius et al. 2019; Stern and Thayer 2019) and are more likely to have high levels of ACEs (four or more ACEs, six or more ACEs (Malvaso et al. 2019)). Despite these consistent findings with samples in the United States and Canada, a study of undergraduate students in Indonesia found the contradictory pattern that men had more ACEs than women (Kaloeti et al. 2019). The mixed patterns of prevalence by gender may result from vulnerability to specific types of ACEs. In the original ACE Study data, men were more likely than women to report physical abuse (Whitefield et al. 2003). In other studies, men reported greater rates of incarceration of household member, emotional abuse, child abuse, and household challenges (Wang et al. 2019), and women reported greater rates of sexual abuse, bullying, and peer violence (Wiehn et al. 2018). In addition to demographic differences, children raised in households with greater economic and residential instability tend to have higher levels of ACEs. The prevalence and number of ACEs are higher for people raised in households with low income under 100% or 200% of poverty level (Beal et al. 2019; Blair et al. 2019; Heard-Garris et al. 2018). Residential instability may also be an aspect of, or proxy for, economic instability. The probability of exposure to any ACEs and the ACE score are positively related to the number of residential moves during childhood. Children who move more frequently tend to experience more ACEs (Dong et al. 2005). Childhood homelessness also is associated with greater history of ACEs. While 62.8% of adults who did not experience childhood homelessness had one or more ACEs, 97.3% of adults who experienced childhood homelessness had one or more ACEs. Further, they had higher total ACE scores than adults who did not experience childhood homelessness (Radcliff et al. 2019).

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Research is also beginning to identify other populations that may be more vulnerable to ACEs. For example, prevalence of ACEs is higher for LGBTQ+ than heterosexuals among non-Asian and Pacific Islander groups. The same pattern is not seen with Asian and Pacific Islanders (Sieben et al. 2019). Children with autism and other special healthcare needs may be particularly vulnerable to ACEs. Prevalence of ACEs is higher in children with special healthcare needs (HeardGarris et al. 2018). Children with autism are more likely to have experienced several types of ACEs, such as parental divorce, death of parent, and having a person in the household with a mental illness, than are children without autism (Rigles 2017). Autism characteristics may also alter children’s perception of and reactions to stressful events such that they are more traumatic than for children without autism (Rigles 2017).

Cumulative, Dose-Response Effect of ACEs The second key finding from the original ACE Study is that cumulative ACEs predicted multiple measured health conditions, with the risk of each outcome increasing along with the ACE score. Experiencing any ACE increased both prevalence and risk for several risk factors and disease conditions, including smoking, severe obesity, physical inactivity, depressed mood, suicide attempts, alcoholism, use of illicit drugs, injection of illicit drugs, more than 50 past sex partners, history of STDs, ischemic heart disease, cancer, chronic bronchitis or emphysema, history of hepatitis or jaundice, skeletal fractures, and poor selfrated health. Risk for each factor increased as the number of ACEs increased (Felitti et al. 1998). Later research has replicated and expanded upon this finding of a doseresponse relationship to additional biomedical outcomes. ACEs increase the risk of premature death (Appleton et al. 2019) and have a wide range of shortand long-term effects on health and well-being, escalating with the number of types of ACEs experienced. Outcomes are evident during childhood as well as during adulthood (Sciaraffa et al. 2018). Based on the original ACE Study and the Behavioral Risk Factor Surveillance System in the United States, the Centers for Disease Control (2019) proposes negative outcomes of ACEs across several life domains, including injury, mental health, maternal health, infectious disease, chronic disease, and risky behaviors. ACE-related outcomes have an estimated annual cost of $233 billion to $938 billion in Europe and $48 billion to $1 trillion in North America (Bellis et al. 2019).

ACEs and Health ACEs increase risk for many negative health outcomes (Bellis et al. 2018; Bellis et al. 2019; Rigles 2017) starting in utero and continuing through childhood and adulthood and affecting subsequent generations (Gentner and O’Connor Leppert

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2019). Children (Bellis et al. 2018) and adults (Felitti et al. 1998; Gilbert et al. 2010; Hughes et al. 2017) with more ACEs have higher odds of poor overall health than those with fewer ACEs. As the number of ACE categories increases, likelihood increases for general physical health complaints (Slavich et al. 2019), infections and illness, shorter height, late age of menarche (Oh et al. 2018), disability (Gilbert et al. 2010), autoimmune disorders (Dube et al. 2009), chronic emphysema, history of hepatitis or jaundice, skeletal fractures, (Felitti et al. 1998), somatic complaints (e.g., headaches, nausea (Oh et al. 2018)), digestive conditions (Bellis et al. 2018), chronic disease (Chang et al. 2019), cancer (Felitti et al. 1998; Hughes et al. 2017), and developmental delay (Cprek et al. 2019). Research consistently documents greater odds of cardiovascular disease (e.g., high cholesterol, ischemic heart disease, myocardial infarction, coronary heart disease, strokes) for people with ACEs than for those without ACEs (Appleton et al. 2019; Felitti et al. 1998; Gilbert et al. 2010; Hughes et al. 2017; Su et al. 2015). Evidence is mixed for some health issues. Some studies find a significant relationship between number of ACEs and respiratory conditions (Felitti et al. 1998; Gilbert et al. 2010; Hughes et al. 2017; Oh et al. 2018) and others not (Bellis et al. 2018). Similarly, evidence is mixed regarding the link between ACEs and type 1 diabetes (Felitti et al. 1998). Although several studies link ACEs to obesity (e.g., Bellis et al. 2019; Felitti et al. 1998), the relationship may be weak to moderate (Hughes et al. 2017) and vary at different ages (Oh et al. 2018) or by geographic location (e.g., stronger in North America than in Europe (Bellis et al. 2019)).

ACEs and Substance Use ACEs also increase risk of use and abuse of alcohol and drugs. People with a history of ACEs are more likely to ever use illicit drugs (Dube et al. 2003; Felitti et al. 1998) and tend to experiment with alcohol and drugs at an earlier age (Lovallo et al. 2019) than people without a history of ACEs, possibly promoted by higher odds of having substance-using peers (Connolly and Kavish 2019) or parents (Dube et al. 2003). After experimentation, ACE score is positively related to heavy alcohol use (Felitti et al. 1998; Hughes et al. 2017) and higher levels of substance use (Brumley et al. 2017). ACEs also increase odds of problematic or addictive use of alcohol and drugs (Bellis et al. 2019; Dube et al. 2003; Felitti et al. 1998; Hughes et al. 2017; Wiehn et al. 2018).

ACEs and Mental Health Beyond addiction, ACEs have several detrimental effects on psychological wellbeing, such as having more negative views of self, life, and others. Average well-being and life satisfaction are lower for people with one or more ACEs (Mosley-Johnson et al. 2019). More ACEs are related to more frequent feelings of mental distress (Gilbert et al. 2010; Manyema et al. 2018), adult life stress (Hillis

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et al. 2004; Manyema et al. 2018), and psychological injury from a perceived act of a moral violation (Battaglia et al. 2019). Adversity in childhood damages people’s subsequent global self-worth and self-esteem (Weiler and Taussig 2019) and may give them more pessimistic expectations of their lives. For example, high school students with more ACEs were more likely to expect that they were going to be killed by 21 years old than students with fewer or no ACEs (Brumley et al. 2017). Psychological consequences of ACEs extend to diagnosable mental illness, with ACEs accounting for approximately 29.8% of all adult mental disorders (Kessler et al. 2010). As ACEs increase, risk of mental illness also increases (Appleton et al. 2019; Edwards et al. 2003; Hughes et al. 2017; Rigles 2017). Prevalence of ACEs is higher for samples in clinical settings. For example, 85% of veterans in an outpatient mental health clinic (Laird and Alexander 2019) had one or more ACEs. Number and severity of life stressors predicted mental health complaints and psychiatric diagnoses for adolescents admitted to a psychiatric residential treatment program (Slavich et al. 2019). Post-traumatic stress disorder (PTSD), depression, and anxiety are common outcomes of ACEs (Chang et al. 2019; Espeleta et al. 2019; Kaloeti et al. 2019; Manyema et al., 2018; Stern and Thayer 2019; Weiler and Taussig 2019; Young-Wolff et al. 2019). Prenatal and postpartum depression and PTSD may also be consequences of ACEs (Mersky and Janczewski 2018). On the more severe end, risks of self-harm, suicidality, and suicide attempts during childhood and adulthood also are greater for people with more ACEs (Dube et al. 2001; Felitti et al. 1998; Russell et al. 2019; Wiehn et al. 2018).

ACEs and Behavioral Problems The effects of ACEs manifest themselves outwardly as an increase in the risk of behavioral problems, including delinquent and criminal behavior. ACEs are associated with greater risk for and higher levels of internalizing problems, externalizing problems (van Duin et al. 2019), delinquent behavior, and criminal behavior (Connolly and Kavish 2019). Youth involved with the justice system have a higher prevalence of ACEs than those who are not (e.g., 75% of youth on community probation in Washington had one or more ACEs (Logan-Greene et al. 2017)). People with ACEs are more likely to engage in violent behavior and have violent criminal convictions, especially when they were the victim of violent ACEs. High school students with ACEs engaged in more violent behavior, but not nonviolent problem behavior, than students without ACEs (Brumley et al. 2017). Youth with violent convictions have higher average ACE scores than those with nonviolent convictions (Malvaso et al. 2019). With adults, perpetrating intimate partner violence (IPV) is more likely for people with more ACEs (Whitefield et al. 2003), and IPV offenders have higher average ACE scores than nonviolent offenders (Hilton et al. 2019). Several ACEs are violent in nature, and there is strong evidence indicating that children who are victims of violence may become perpetrators of violence as adults (Connolly and Kavish 2019).

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ACEs and Other Outcomes Experiencing ACEs is also associated with negative social, cognitive, and academic outcomes (Brumley et al. 2017; Connolly and Kavish 2019; Oh et al. 2018). Odds of having a social delay increases by 17% with each ACE (Cprek et al. 2019). ACEs damage the quality of social relationships and create weak social networks (Larkin et al. 2014), family problems (Hillis et al. 2004), and extreme social isolation or withdrawal (Frankova 2019). Students with ACEs are less engaged with school, as demonstrated by higher rates of absences (Bellis et al. 2018) and not completing homework (Kasehagen et al. 2018), and have lower expectations of going to college (Brumley et al. 2017) than students without ACEs. Actual academic performance varies as well. Students with more ACEs have lower grade point averages than students with fewer ACEs (Kaloeti et al. 2019), and college graduates are likely to have fewer ACEs than non-college graduates (Stern and Thayer 2019). ACEs predict greater economic problems and lower income during adulthood. Household income per month is associated with ACEs (Ji and Wang 2018). Specifically, having more ACEs increases risk for having low income (Nurius et al. 2019). People with ACEs are more likely to have job problems and financial problems (Hillis et al. 2004).

Scope of Adverse Experiences Since 1998, the scope of adverse experiences has broadened beyond the original ten ACEs, treating ACEs less as a comprehensive list of specific adverse experiences and more as a framework for understanding the short- and long-term impact of early childhood experiences on development and well-being (Espeleta et al. 2019). Many studies have measured the same types of ACEs as the original ACE Study, using either the ACE Survey or different tools (e.g., Appleton et al. 2019; Kaloeti et al. 2019; Lange et al. 2018), while others use all but selected ACEs based on the population being sampled. For example, Hinojosa and colleagues excluded physical abuse, sexual abuse, and neglect (Hinojosa et al. 2019), and Espeleta et al. (2019) excluded physical neglect and parental separation/divorce. There is growing evidence that additional ACEs, such as economic adversity (Braveman et al. 2018) or having a chronic health condition as a child (Espeleta et al. 2019), beyond the original ten may significantly predict health and well-being outcomes (Radcliff et al. 2019). Measures of ACEs have expanded to include a wide range of ACEs, beyond the original ten ACEs in Felitti et al.’s (1998) ACE Questionnaire. For example, several studies used the Adverse Childhood Experiences International Questionnaire (ACEIQ), created by the World Health Organization (2018), which measures the original ten ACEs and bullying, peer violence, community violence, and collective violence (e.g., Brajovic et al. 2019; Chang et al. 2019; Ho et al. 2019). Several other studies use data from the Behavioral Risk Factor Surveillance System, a national telephone

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survey by the Centers for Disease Control in the United States, which added socioeconomic hardship, victim or witness of neighborhood violence, and having been treated unfairly due to race/ethnicity (e.g., Cprek et al. 2019; Ji and Wang 2018). A few studies take the broadest scope for ACEs by using the Childhood Trauma Questionnaire, which asks about any major upheaval the respondent thinks may have shaped their life (e.g., Ji and Wang 2018; Shin et al. 2019). Family economic hardship is one of the most common expanded ACEs (e.g., Heard-Garris et al. 2018; Lew and Xian 2019; Mosley-Johnson et al. 2019). Neighborhood and school disadvantage may also be an ACE (Brumley et al. 2017). Other expanded ACEs included exposure to foster care (Brumley et al. 2017); adoption (Mosley-Johnson et al. 2019); caregiver’s absence or other loss of contact with parents (not including death (Mosley-Johnson et al. 2019; Olofson 2018; Wiehn et al. 2018; Weiler and Taussig 2019)); major accidents or serious illness (Rieder et al. 2019); major accident, serious illness, or death of loved one (not limited to parent (Ji and Wang 2018; Rieder et al. 2019; Shin et al. 2019)); natural disasters, fires, war, and terrorism (Rieder et al. 2019); and exposure to non-family threats in the home or at school (Connolly and Kavish 2019).

Different Approaches to Models of ACEs Although the studies on consequences of ACEs provide substantial support for a model of cumulative risk for ACEs, more appropriate models may be multiplicative or domain-specific. Cumulative models approach each type of adversity as equal, with higher scores interpreted in the same manner regardless of which specific ACEs comprise the score (Beal et al. 2019). Contrary to this approach, a model of cumulative risk that weighted each ACE equally did not fit as well as an unconstrained model (Olofson 2018). Multiplicative models, which explore how specific ACEs may exaggerate the effects of other ACEs, may be an alternative to cumulative models. For example, a study using the original ACE Study data found that moderate emotional abuse intensified the relationship between other ACEs and poor mental health, when combined with all other types of abuse; however, severe emotional abuse without the addition of sexual or physical abuse and witnessing domestic violence exhibited the opposite pattern, predicting better mental health (Edwards et al. 2003). Another alternative approach is domain-specific models of ACEs, in which some ACEs may be more stressful than others or more strongly linked to specific health outcomes (Simons et al. 2019). Each type of adversity experienced during childhood may be differentially associated with health and well-being (Beal et al. 2019). Different ACEs have stronger associations than others with mental health (Brajovic et al. 2019; Cprek et al. 2019). The direction and strength of relationships between child maltreatment, social disadvantage, and family dysfunction types of ACEs with mental health outcomes may vary (Logan-Greene et al. 2017; van Duin et al. 2019). Physical types of ACEs have stronger relationships with alcohol use than emotional

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types of ACEs (Brajovic et al. 2019). The sexual risk behavior of having more than 30 sexual partners (Hillis et al. 2001) and somatic complaints (Oh et al. 2018) are related to some, but not all, types of ACEs. While emotional abuse, physical abuse, household violence, household substance abuse, and having an incarcerated household member increased risk of externalizing behaviors, sexual abuse and living with a household member with mental illness lower the risk of externalizing behavior (Muniz et al. 2019). Emotional neglect predicts suicidality, while physical neglect, emotional abuse, and peer violence predict problematic drinking (Wiehn et al. 2018). The domain-specific variations may combine with the frequent co-occurrence of different ACEs to create constellations or profiles of adversity with unique sets of covariates and outcomes. Model comparisons support exploration of the nature and pattern of ACE profiles, rather than cumulative ACEs (Ho et al. 2019). For example, a model with three dimensions of ACEs had better predictive power for several health outcomes than did a model with total ACE score or models with each ACE dimension, separately. Although the total ACE score predicted almost every health outcome, models with each ACE dimension predicted a different group of outcomes, which supports domain-specific ACE modeling; however, the model including all three ACE dimensions revealed that the direction and strength of prediction changed for some outcomes as compared to total ACE score and individual dimension models. By looking at cumulative ACE score, specific relationships with ACEs are hidden. When looking at the models with only one ACE dimension, there were several false positives for outcomes (Westermair et al. 2018). Increasingly more often, latent class analysis (LCA) is the preferred method for identifying profiles of ACEs by examining underlying patterns between observed ACEs (Ho et al. 2019; Lew and Xian 2019). Profiles of ACEs from LCA distinguish between people with high ACE exposure, low ACE exposure, and primary exposure to specific groups of ACE types (including household dysfunction, family violence, physical/sexual and emotional abuse, divorce, and economic hardship), and these profiles differentially predict health and well-being outcomes. Olofson (2018) found that a model with two factors, household dysfunction and abuse, fit the data better than a model that did not distinguish between the types of ACEs. Beal et al. (2019) supported a similar model, separating family instability from violence. Several studies found classes of low and high ACEs along with domain-specific classes, such as a three-class model with low ACEs, household violence, and household dysfunction (Ho et al. 2019) and a four-class model with income hardship only, divorce only, mental illness or substance abuse only, or high ACEs overall (Lew and Xian 2019). It may be that type distinguishing between ACEs is more relevant at moderate levels of ACEs than at high or low levels of adversity. Wolff and colleagues found support for a five-class model, including high ACEs, low ACEs, moderate ACEs with high emotional abuse, moderate ACEs with high physical and sexual abuse, and moderate ACEs with high household substance abuse and incarceration (Wolff et al. 2018). For each of the studies, the different classes differentially predicted health and mental health outcomes. Other profiles of ACEs distinguish between people with different trajectories of adversity from childhood to adolescence. Risk of depression varies for children with

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stable low ACEs, stable mild ACEs, moderate ACEs after birth and mild by late childhood, mild ACEs after birth increasing to high ACEs by late childhood, and stable high ACEs (Tracy et al. 2019). When considering ACEs in the family and community, the trajectory of family conflict and community violence from middle school to high school yielded different patterns of violent teen dating behaviors. Decreasing family conflict and increasing community violence from middle to high school contributed the most to high levels of teen dating violence. Stable high family conflict and community violence during both middle and high school contributed to physical and verbal teen dating violence, while stable low family conflict and community violence during both middle and high school contributed to low overall teen dating violence (Davis et al. 2019).

Causal Pathways from ACEs to Outcomes There are several causal pathways from ACEs to later child and adult outcomes. Experiencing adversity in infancy and early childhood creates chronic stress, which has cascading effects on almost every system, tissue, and cell in the body and increases risk for health-harming behaviors (Bellis et al. 2018; Oh et al. 2018; Su et al. 2015). Bodies attempt to cope and adapt to stressful conditions, but repeated stress early in life may overload and dysregulate stress response systems and damage adaptive responses to stress later in life (Appleton et al. 2019; Larkin et al. 2014; Manyema et al. 2018).

Chronic Overactivation of Hypothalamic-Pituitary-Adrenal (HPA) Axis ACEs change how the nervous and hormonal systems interact (i.e., the neuroendocrine system) through the hypothalamic-pituitary-adrenal (HPA) axis (Gentner and O’Connor Leppert 2019; Laird and Alexander 2019). The first casual pathway for outcomes of ACEs is through chronic overactivation of the HPA axis in response to stress (i.e., ACEs (Neves et al. 2019; Sciaraffa et al. 2018)). The HPA axis controls stress reactivity, release of stress hormones, the immune system, mood, cognition, metabolism, and other fundamental bodily processes. When activated, the hypothalamus (a part of the HPA axis located in the central lower area of the brain, just above the brainstem) produces corticotrophin-releasing and arginine vasopressin hormones. The corticotrophin-releasing hormone travels a short distance through a portal of blood vessels to the anterior pituitary gland, triggering the secretion of adrenocorticotropic hormones into the bloodstream. Once that hormone reaches the adrenal glands (located just above the kidneys), the outer part of the adrenal glands (the adrenal cortex) produces glucocorticoids (e.g., cortisol/corticosterone). Repeated activation of the HPA axis in response to ACEs can lead to hyperactivity of the HPA axis and overproduction of cortisol (Aulinas et al. 2013) or lead to

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exhaustion of the HPA axis and underproduction of cortisol, blunting reactivity to stress (Aulinas et al. 2013; Lovallo et al. 2019). These changes in HPA activity and cortisol levels may damage the health of cells, shortening their lifespan and ability to repair themselves, as seen through shortening of telomeres. Telomeres are proteins located at the ends of each chromosome, as protection from damage during replication. With each division during replication, the DNA is shortened, and the telomerase enzyme partially repairs that damage. When telomeres become too short, the DNA is unprotected and either stops replicating or dies. Changes in cortisol levels due to ACEs may alter the telomerase process and accelerate the shortening of telomeres (Aulinas et al. 2013). People with ACEs have shorter telomeres than people without ACEs (Oh et al. 2018; Sciaraffa et al. 2018). Telomere length is associated with chronological age, as well as a wide range of health and mental health issues, such as cancer, lesions, anemia, fibrosis of the lungs and liver, cardiovascular disease (Aulinas et al. 2013), and depression (Aulinas et al. 2013).

DNA Methylation After the release of glucocorticoids, the second causal pathway for outcomes of ACEs, DNA methylation of genes within the HPA axis, begins (Argentieri et al. 2017; Gentner and O’Connor Leppert 2019). DNA methylation is a process that can change the activity of a gene without changing its DNA structure. Glucocorticoids travel back through the bloodstream and bind to glucocorticoid receptors in the anterior pituitary gland, hypothalamus, and hippocampus in the brain, stopping the production of the corticotrophin-releasing and adrenocorticotropic hormones (i.e., stopping the stress response (Argentieri et al. 2017)). When bound to the glucocorticoids, the glucocorticoid receptor moves to the cell nucleus and modifies the synthesis of proteins. If the glucocorticoid receptor binds directly to a glucocorticoid response element in the nuclear DNA, it may trigger the synthesis of additional immunity- and metabolic-related cytokines (proteins that regulate the immune system), a process called transactivation. If the glucocorticoid receptor does not bind with the nuclear DNA, it may repress the transcription activity (i.e., expression) of the genes in the DNA responsible for production of immunosuppressive and proinflammatory cytokines, a process called transrepression. Research provides strong evidence that DNA methylation of HPA axis genes causes hypertension, breast cancer, small cell lung cancer, chronic kidney disease, Alzheimer’s disease, PTSD, depression, and anxiety. Evidence is mixed for coronary heart disease, bipolar disorder, and bipolar personality disorder (Argentieri et al. 2017).

Alteration of Immune and Inflammatory Functions DNA methylation and cortisol dysregulation may lead to the third casual pathway for ACEs, alterations of immune and inflammatory functions. ACEs result in

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maladaptive immune function (Laird and Alexander 2019) and inflammatory responses throughout the body (Oh et al. 2018), contributing to most autoimmune diseases (Dube et al. 2009). DNA methylation may activate or suppress production of immunity- and inflammation-related cytokines. There is substantial evidence of a feedback loop between cortisol and cytokines in functions of the HPA axis. Certain inflammatory cytokines may activate the HPA axis, and cortisol may have an antiinflammatory effect by suppressing the release of more cytokines (Turnbull and Rivier 1999). High levels of inflammatory cytokines indicate chronic activation of the immune system and systemic inflammation (Russell et al. 2019). Overproduction of cortisol may damage the function of glucocorticoid receptors, reducing the body’s capacity to regulate levels of cortisol and cytokine release (Turnbull and Rivier 1999). ACEs are associated with the higher levels of the inflammatory cytokine, interleukin-6 (IL-6 (Russell et al. 2019)) and endothelin-1 (ET-1; Su et al. 2015). Some ACEs may be more strongly related to inflammation than others (e.g., Simons et al. 2019).

Alterations to Brain Structure and Function ACEs that occur early in life also result in structural and functional changes to the brain (Sciaraffa et al. 2018; Laird and Alexander 2019), a fourth causal pathway. Studies using magnetic resonance imaging (MRI) reveal that children who experienced maltreatment or severe deprivation have larger amygdala volume, and smaller total brain, white and gray matter, and callosum and hippocampal volume than other children. Brain volume is related to the age of onset and duration of children’s traumatic experiences and post-traumatic stress disorder, such that brain volume is lower when the trauma begins at an earlier age and lasts for a longer duration (De Bellis and Zisk 2014). Brain function also changes with exposure to ACEs. Stress from ACEs interferes with the brain’s regulation of the neurotransmitter glutamate and interacts with the genes that manage the release of glutamate to alter the structure of white matter in the brain (Poletti et al. 2019).

Alterations to Emotion and Behavior Regulation In addition to the neurobiological mechanisms, ACEs reduce people’s ability to control their emotions and behaviors (the fifth causal pathway), affecting engagement in behaviors that put their health and well-being at risk. ACEs lower people’s ability to inhibit thoughts to switch to another task (Ji and Wang 2018). People with ACEs tend to be less able to manage their emotions (referred to as emotion dysregulation (Espeleta et al. 2019)) and act more rashly when experiencing a high level of distress (referred to as negative urgency (Shin et al. 2019)). The relationship between ACEs and depression and anxiety is partially accounted for by emotion dysregulation (Espeleta et al. 2019).

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Lower inhibitory and regulatory ability can contribute to making poor decisions about health and reliance on negative coping behaviors (Neves et al. 2019). Experiencing chronic adversity during childhood is associated with greater engagement in risk behaviors, with more ACEs predicting more risk behaviors (Slavich et al. 2019; Wiehn et al. 2018). The generally unrecognized point here is that the focus on evident long-term risks of behaviors overlooks that the behaviors may yield short-term benefits in response to the experience of adversity (e.g., Felitti and Williams 1998). For instance, exposure to ACEs predicts greater likelihood and frequency of smoking (Chang et al. 2019; Felitti et al. 1998; Hughes et al. 2017; Wiehn et al. 2018; Young-Wolff et al. 2019). While the psychoactive benefits of inhaled nicotine, like reduced anxiety and tension, occur within 15–20 s, the major long-term risks occur 15–20 years later. The same concept applies to sexual risk taking (Hillis et al. 2001; Hughes et al. 2017), such as early sexual intercourse (Felitti et al. 1998; Hillis et al. 2001; Wiehn et al. 2018), having multiple lifetime sexual partners (Hillis et al. 2001; Wiehn et al. 2018), risk or history of AIDS or other STDs (Felitti et al. 1998), adolescent pregnancy (Hillis et al. 2001), and unintended pregnancy (Dietz et al. 1999). ACEs may also contribute to lower levels of physical activity (Felitti et al. 1998; Hughes et al. 2017).

Intergenerational Epigenetic Effects of ACEs The effects and causes of ACEs extend beyond the lifespan of the child who experienced the adversity, with intergenerational effects of ACEs starting during pregnancy. Females are born with all their eggs, based on the health of their grandmother’s pregnancy (Gentner and O’Connor Leppert 2019), meaning alterations in fertility, and genetic composition and expression (i.e., epigenetics) due to ACEs pass through multiple generations. Further, ACEs increase adult stress levels, and maternal stress transfers to the unborn children by affecting the levels of oxygen, nutrients, and hormones in the womb. Fetal cortisol levels caused by glucocorticoids from maternal stress also alter regulation of the fetal HPA axis in utero. This directly affects the growth of developing organs, insulin regulation, and later risk for diabetes, heart disease, and hypertension. Further, it shapes the activation of suppression of genes (via the epigenetic processes of transactivation and transrepression (Gentner and O’Connor Leppert 2019)). Intergenerational epigenetic effects of ACEs continue after birth, as demonstrated by risk for negative birth and parenting outcomes. Higher levels of maternal ACEs are associated with greater risk of fetal death (Hillis et al. 2004) and higher cephalization scores for newborns (the ratio of head circumference to weight, an indicator of fetal development for which higher scores reflect greater risk for brain vulnerability (Appleton et al. 2019)). Mothers with ACEs tend to experience higher levels of parenting-related stress, increasing with the number of ACEs (Lange et al. 2018). Given the victim-offender cycle of violence and connection between ACEs and emotional dysregulation, it is also reasonable to expect higher rates of violent

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parenting behaviors and children’s exposure to family violence when either or both parents have violent ACEs.

Protective Factors Variability in the mechanisms and outcomes of ACEs later in life suggests that factors, such as timing and severity of adversity and environmental factors, may facilitate or buffer against ACEs’ multiple causal pathways to outcomes (Oh et al. 2018). Although some are evident during childhood, the causes and consequences of ACEs may be partially triggered or exacerbated by exposure to stress during adulthood. People with ACEs are more likely to experience distress in response to stress during adulthood, with a lower threshold of severity of adult stress, than people without ACEs (Manyema et al. 2018). People may be more sensitive to stressful adult experiences that are of the same type as those they experienced as children (Simons et al. 2019). Adult adversity partially mediates the relationship between ACEs and health behaviors and mental health (Manyema et al. 2018; Nurius et al. 2019). While adult stress may trigger negative outcomes of ACEs, protective factors may reduce or buffer against the effects of ACEs. Protective factors cultivate strengths and reduce the negative outcomes of ACEs (Larkin et al. 2014). Evidence for the protective role of having social support, such as a role model and supportive friends, is mixed. Some studies find social support is related to lower levels of negative outcomes for people with ACEs (e.g., Bellis et al. 2018; Davis et al. 2019). For example, social support protects against suicidality. When youth experience high levels of childhood victimization and later have low levels of social support, they have a greater risk for suicidal ideation (Logan-Greene et al. 2017). Social support during pregnancy, as measured by reports of tangible support and feelings of belonging, buffer against the negative birth outcome of elevated cephalization scores for mothers with low and moderate ACEs (but not for those with high ACEs (Appleton et al. 2019)). Other studies, however, have found that social support did not account for, weaken, or alter the nature of the relationships between ACEs and physical and mental health (Nurius et al. 2019). Evidence for the protective role of family and community assets is consistent for low and moderate levels of ACEs and mixed for high levels of ACEs. High socioeconomic status during childhood buffers against negative outcomes for each type of ACE and cumulative ACEs (Wiehn et al. 2018). For education level, specifically, protection against the damage of ACEs to mental health symptoms is only evident with low and moderate ACEs, not with high ACEs (Rieder et al. 2019). Children raised with access to more community assets are less likely to experience ACEs (Bellis et al. 2018). Living in communities that parents consider safe and cohesive, with assets, such as sidewalks, recreation centers, libraries, and parks, increases the likelihood that children are resilient to adversity (Heard-Garris et al. 2018). Transportation may be particularly important for people experiencing economic adversity. Above the poverty line, access to housing, transportation, and

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breastfeeding education protects against ACEs; however, below the poverty line, only transportation protects against ACEs (Blair et al. 2019). Unlike external protective factors, resilience gives people internal protection against the effects of ACEs. Resilience, the ability to rebound or positively adapt despite experiencing adversity can reduce or eliminate the negative outcomes of ACEs (Heard-Garris et al. 2018; Sciaraffa et al. 2018). Resiliency partially mediates the relationships between ACEs and physical and mental health issues (Rigles 2017). With more adverse experiences, however, it may be difficult to maintain high levels of resilience. People with higher ACE scores have lower odds of resilience (HeardGarris et al. 2018), and with each additional ACE, the odds of resilience decline (Kasehagen et al. 2018).

Summary and Conclusion In summary, the ACE Study is a retrospective and 20-year prospective study of 17,337 middle-aged, middle-class adults showing the powerful relationship, decades later, of ten unexpectedly common, often concealed, categories of adverse childhood experiences on adult well-being, occupational success, biomedical health, and life expectancy. It has progressively attracted worldwide attention among researchers and practitioners in the 22 years since the publication of its initial publication in 1998. Although there is some evidence of advances in schools, policing, judicial systems, legislation, and medical practice, the need for awareness and action with the general public remains substantial. Given the high prevalence rate of ACEs and their extensive consequences, destigmatizing and normalizing talking about and screening for trauma is a critical first step toward prevention and treatment. Every person and entity that deals with children has a part to play in protection from adversity. While many people hold back from discussing topics that they think children may not be ready for, many children are already experiencing those topics, or worse, firsthand. Adult fear of acknowledging the potentially terrible occurrences in children’s lives is a barrier to building safe environments with resilient children. Universal trauma screening by medical care providers could be an initial opportunity to limit the damage of ACEs and prevent future ACEs from occurring. Prevention of violence in homes, schools, and communities is another critical area of focus. Because of the difficulty in treating the consequences of ACEs after the fact, primary prevention is of profound importance. Funding and services should prioritize working with parents, providers, educators, and other community members on how to effectively interact with and support children. Strengthening caretaking skills inside and outside of the home will directly prevent family violence and provide buffering social networks for children to lean on in times of need. Encouraging parent resiliency and child resiliency through developing emotional regulation, stress management and coping, and relationship-building techniques, along with connecting families to resources for social, economic, mental health, and medical support in their community, could considerably reduce the likelihood and frequency of ACEs.

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Key points • In 1998, multiple disciplines evolved with the introduction of Adverse Childhood Experiences (ACEs) research. Understanding ACEs moved research from individual risk toward cumulative risk and its impact, as well as highlighted the critical importance of early childhood experiences on well-being throughout the lifespan. • The first key finding from the original ACE Study is that ACEs were unexpectedly common, and exposure to one ACE dramatically increased the chances of exposure to additional ACEs. Subsequent studies throughout the United States and other countries have supported this finding. Prevalence rates vary but remain relatively high, and studies consistently find that exposure to one ACE increases the odds of exposure to additional ACEs. • The second key finding from the original ACE Study is that cumulative ACEs predicted multiple measured health conditions, with the risk of each outcome increasing along with the ACE Score. ACEs have a wide range of short- and longterm effects on health, substance use and abuse, psychological well-being, diagnosable mental illness, behavioral problems, including delinquent, criminal, and violent behavior, social, cognitive, and academic development, and economic problems, escalating with the number of ACEs experienced. Outcomes are evident during childhood as well as adulthood. • Model comparisons support exploration of the nature and pattern of ACE profiles, rather than cumulative ACEs. Multiplicative models, which explore how specific ACEs may exaggerate the effects of other ACEs, may be an alternative to cumulative models. Another alternative approach is domain-specific models of ACEs, in which some ACEs may be more stressful than others or more strongly linked to specific health outcomes. Latent Class Analysis (LCA) is emerging as the preferred method for identifying profiles of ACEs by examining underlying patterns between observed ACEs. • There are several causal pathways from ACEs to later child and adult outcomes. The first casual pathway is through chronic overactivation of the hypothalamic-pituitary-adrenal (HPA) axis in response to stress. The second causal pathway is through DNA methylation of genes within the HPA axis. DNA methylation is a process that can change the activity of a gene without changing its DNA structure. DNA methylation and cortisol dysregulation may lead to the third casual pathway, maladaptive alterations of immune and inflammatory functions. ACEs that occur early in life also result in structural and functional changes to the brain, a fourth causal pathway. In addition to the neurobiological mechanisms, ACEs reduce people’s ability to control their emotions and behaviors (the fifth causal pathway), affecting engagement in behaviors that put their health and wellbeing at risk. • The effects and causes of ACEs extend beyond the lifespan of the child who experienced the adversity, with intergenerational effects of ACEs starting during pregnancy and continuing after birth.

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• Although there is some evidence of advances in schools, policing, judicial systems, legislation, and medical practice, the need for awareness and action with the general public remains substantial. • De-stigmatizing and normalizing talking about and screening for trauma is a critical first step toward prevention and treatment. Universal trauma screening by medical care providers could be an initial opportunity to limit the damage of ACEs and prevent future ACEs from occurring. Prevention of violence in homes, schools, and communities is another critical area of focus. Because of the difficulty in treating the consequences of ACEs after the fact, primary prevention is of profound importance.

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Trauma-Informed Systems of Care Karen Rich and Megan R. Garza

Contents Trauma, Interpersonal Violence, and Social Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Secondary Survivors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trauma and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trauma-informed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Awareness of Trauma and Its Impact: Rrrrs in Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trustworthiness and Transparency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Empowerment and Choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Peer Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Collaboration and Mutuality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cultural, Historical, and Gender Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Attention to Secondary Survivors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Organizational Structure and Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Agency Self-assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Collaboration with Trauma-Informed Partner Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Individual Level Barriers to Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Counter-Transference, Vicarious Trauma, and Burnout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Attitudes Towards Traumatized Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter will focus on the issues, research, practice, policies, and current state of the science of trauma-informed care for interpersonal violence and abuse and serve as a basis for conceptualizing best practices for reducing the various forms of interpersonal violence that will be addressed more fully in the chapters to come. This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. K. Rich (*) Department of Social Work, Marywood University, Scranton, PA, USA e-mail: [email protected] M. R. Garza Healing Reflections Therapy, St. Louis, MO, USA © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_293

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Self-protection and the “Just World” Hypothesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Agency Level Barriers to Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Resistance to Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cultural and Ideological Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Turf Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lack of Knowledge and Fear of Trauma Contagion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Financial Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Workplace Bullying and Sexual Harassment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Innovations in Assessment and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Controversies, Questions, and Issues for Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Survivors of interpersonal trauma are vulnerable to risk of re-victimization when seeking help from community agencies such as welfare offices, substance abuse clinics, schools, homeless shelters, medical facilities and criminal justice agencies. Re-victimization of trauma survivors can lead to client dropout, “resistant” behavior, and treatment failure. It can also lead to stress, conflict, burnout, and frequent turnover among staff. Trauma-informed care is a community’s best approach to supporting survivors of interpersonal violence, but many agencies under-estimate its value or lack a comprehensive approach to its implementation. Budgetary concerns, resistance to change, turf issues, hierarchical power structures, lack of training, fears of trauma contagion and negative attitudes towards service recipients contribute to the problems. Interdisciplinary collaboration, investment in prevention, concern for employee wellness and top-down commitment are essential features of trauma-informed agencies. This chapter will present an overview of trauma-informed care, the benefits to clients and providers, obstacles to implementation of best practices, and research initiatives in the field. Keywords

Trauma-informed care · Sanctuary Model · Burnout · Compassion fatigue · PTSD · Adverse child experiences scale (ACES)

Trauma, Interpersonal Violence, and Social Support If you turn on your radio or television set, or read an article on social media, you are very likely to be bombarded with news of the latest mass shooting, immigrants experiencing human rights violations, officer involved shootings, sexual assaults that are covered up, the latest victim of domestic violence, a human trafficking arrest, an incident of racially motivated discrimination, or a case of schoolyard bullying. We are bombarded with messages about interpersonal violence. It’s hard to have a

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discussion with parents that doesn’t devolve into the politics of corporal punishment and what many see as “right because it was done to me.” However, as research indicates, exposure to traumatic experiences exacts a measurable cost to human lives in the form of increased health problems, suicidality risk, and proclivity to abuse substances (Zarse et al. 2019). Thanks to revolutionary findings from the Adverse Childhood Experiences Study (ACES) (Felitti et al. 1998), a rapidly growing body of research has allowed us to better address the mental and physical well-being of our population. This chapter will provide an introduction to some of the main concepts related to trauma-informed care and highlight their importance in creating a healthier, more resilient society. A foundational component of trauma-informed care is understanding the concept of “trauma.” A traumatic event is any experience that overwhelms the individual’s coping capacities and causes the person to engage in reliving, dissociation, and/or avoidance behaviors. Such experiences can include natural disasters, hate crimes, military atrocities, acts of interpersonal violence, distressing medical experiences and pandemics, and extreme/sudden losses. Cultural and historical trauma, resulting from colonization and institutionalized oppression, can be transmitted across generations. For the purposes of this chapter, we will focus on trauma as a result of interpersonal violence. Interpersonal violence takes many forms such as bullying, battering, mugging, torture, stalking and/or sexual abuse, and a myriad of other variations as can be seen in the subsequent chapters of the handbook. These forms of abuse are characterized by threats, boundary violations, humiliation, physical attacks, gaslighting (mischaracterization of motives and events), and/or social exclusion. They do not often occur in isolation; poly-victimization is common. Victims typically experience powerlessness, terror, rage, shame, and/or self-doubt. Over time, conditions such as depression, anxiety, self-injurious behavior, dissociative disorders, attachment disorder, and addictions can occur. When perpetrators and instances accumulate, complex trauma can result; characteristics include distrust, negative coping mechanisms, and relationship difficulties. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines psychological trauma as an event, series of events, or set of circumstances experienced as harmful with lasting emotional, physical, spiritual, social, and mental adverse effects. Components include an upsetting event; a personal experience of it resulting from the survivor’s specific characteristics and history; and a negative effect on the individual’s functioning. As of 2013, the updated Diagnostic and Statistical Manual (DSM-5) (American Psychiatric Association 2013) added and re-classified a variety of trauma-related diagnoses into a section titled “Trauma and Stressor-Related Disorders,” which includes posttraumatic stress disorder, acute stress disorder, and Reactive Attachment Disorder; this stems from a growing appreciation of trauma’s impact on human behavior (Jones and Cureton 2017). Trauma-related sequelae include hypervigilance, dissociation, flashbacks, social withdrawal, alterations in memory and attention, emotional dysregulation, restricted affect, reduced stress tolerance, impaired ability to trust, development of distorted, negative beliefs, and dysregulated eating (APA 2013; Brewerton 2019). Individuals vary in the degree to which an event is perceived as traumatic. This can be influenced by developmental stage at the time of the event, genetic

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predisposition to stress, cultural background, previous history of traumatic exposure, or mitigated by degree of social support (Briere and Scott 2015). Traumatic responses can be delayed or unacknowledged. Children, who lack the cognitive capacity to process events, are more vulnerable. In addition, survivors of interpersonal violence (as opposed to accidents and natural disasters) are often at greater risk of experiencing a trauma related response due to accompanying feelings of betrayal, guilt, and shame. Some individuals experience a more rapid and thorough recovery from trauma as a result of personal resiliency factors and social support. However, many survivors experience prolonged effects which have broad and far reaching consequences. These survivors may expect to be abused, abandoned, or betrayed by authorities and support persons. They may feel cornered, coerced, misled, spied on, disrespected, misunderstood, overlooked, or objectified by agency staff. They may have characteristics such as immigration status, cultural values, or criminal backgrounds that amplify these fears. Through the process of traumatic re-enactment (the tendency of survivors to subjectively re-live earlier traumatic events), they may experience feelings of victimization despite professionals’ sincere attempts to help (Bloom and Farragher 2013). In addition, professionals may unknowingly engage in re-victimizing behavior towards survivors.

Secondary Survivors One does not need to directly experience a trauma to be impacted by it. Family members, partners, and friends of trauma survivors may develop secondary posttraumatic stress symptoms including guilt, anger, fear, shame, revenge fantasies, flashbacks to instances of their own victimization, nightmares, sleep difficulties, and eating disorders (Christiansen et al. 2012; Connolly and Gordon 2014). Secondary survivors can benefit from group support, family therapy and psychoeducation; however, most systems are designed to support individuals rather than the social networks that engulf them (Bloom and Farragher 2013). This is unfortunate given that traumatic symptoms can be transmitted across generations and affect entire cultural groups (Nutton and Fast 2015). Research on epigenetics has begun to demonstrate how genocide, slavery, and forced family separation can change the way genes are expressed in subsequent generations, increasing the likelihood of increased stress responses without direct experience of trauma (Lehrner and Yehuda 2018). Indeed, the aftershocks of trauma can be widespread in their area of impact.

Social Support Although the picture of trauma and its impact may seem bleak, social support has proven crucial to survivors’ recovery. When administered in a timely fashion, it can prevent the development of PTSD (Ullman 2010). Supportive responses include believing survivors, validating their emotions, attending to their safety, offering them

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choices, noting their strengths, allowing them to ventilate, providing concrete assistance, asking what they need, and staying present. Negative reactions include shock, horror, blame, shame, self-centeredness, indifference, attempts to silence or control survivors, and demands that they return to normal. Most social support is provided by loved ones who, as secondary survivors, may be struggling with their own emotional reactions. Formal supports (such as teachers, physicians, child protective workers, shelter staff, church leaders, and criminal justice agents) can behave in helpful and/or unhelpful ways (Ullman 2010). While many respondents provide a mixture of supportive and nonsupportive responses, survivors tend to take negative responses more seriously. As a result, trauma-informed providers make efforts to avoid nonsupportive statements. In addition they take actions that support the recovery of survivors.

Trauma and Health Emerging research over the past two decades has highlighted how critical trauma is to one’s overall physical and mental health. Dr. Vincent Felitti and his team (Felitti et al. 1998) made groundbreaking discoveries while working in a bariatric weight loss clinic. Dr. Felitti noted patients that lost a significant amount of weight postsurgery frequently regained it. After one patient re-gained nearly 40 pounds in a month, Dr. Felitti engaged her from a position of curiosity instead of judgment. The patient disclosed a history of sexual trauma and associated concerns about her new body image. Based on this, a research team created a scale of 10 brief questions to assess adverse childhood experiences before the age of 18 (such as sexual abuse, physical abuse, and exposure domestic violence). This large scale epidemiological study with over 17,000 participants conducted at Kaiser Permanente Health yielded robust data indicating a link between early traumatic experiences and negative health consequences in every domain measured: depression, stroke, COPD, Liver disease, alcoholism, emphysema, risk of perpetrating and being a victim of domestic violence, as well as suicide. Most startlingly, an ACE score of 6 or more was associated with a 20-year shorter lifespan and a 3000% increase in attempted suicide. Indeed, the ACES study is now recognized as a seminal study that spawned many traumainformed models in place today. Additional research has documented the existence of relationships among trauma exposure, impaired immune response, and health disorders, as well as more pain and physical symptoms, lower quality of health, and functional impairments (Gillock et al. 2005; McLeay et al. 2017). Researchers, practitioners, administrators, and front-line staff are beginning to understand how essential prevention of violence and early intervention is to one’s overall health and development. As a result, a growing number of child welfare agencies, police departments, schools, medical facilities, and treatments centers are integrating what has come to be known as “trauma-informed care” into their approaches (Garza et al. 2019a); examples of these include the Thrive Initiative in Maine, the Child Trauma Project in Massachusetts, the Child Health and Development Institute in Connecticut.

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Trauma-informed Care Trauma-informed care is an approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in others’ lives and in our own. It is grounded in an understanding of the neurological, biological, psychological, and social impact of trauma on individuals, families, and communities. It is recognized as a strengths-based, universal precautions approach that encourages awareness that any client may have traumatic experiences in his or her background. It is a means of approaching survivors so they benefit from services and are not re-traumatized. It attempts to minimize “noncompliant” behavior and dropout among clients by asking what has happened to a person, versus what is wrong with them (SAMHSA 2014). Attending to the emotional reactions of care providers may also decrease staff burnout and turnover (Bloom and Farragher 2013). Interest in trauma-informed practice arose in the 1990s from an awareness that in various “helping” professions there are coercive practices that may re-victimize survivors. These include the use of seclusion and restraints in psychiatric hospitals (Bryson et al. 2017); abrupt removal of children from their parents by judges and child welfare workers (Lens 2017); police use of ineffective interrogation techniques with rape survivors (Rich 2019); intrusive and poorly explained medical procedures (Hamberger et al. 2019); and excessively harsh discipline in schools (Guckenberg et al. 2016). Trauma-informed care is not a series of treatment approaches (which are defined as trauma-informed interventions) but a philosophy of care and set of overarching principles based on ongoing research. SAMHSA (2014) has identified 4 general goals of trauma-informed care from which specific aspects are generated. A program, organization, or system that is trauma-informed is one that creates a contextual milieu and a culture of delivering care and services to people impacted by trauma in a way that: 1. Realizes the impacts of trauma and understands potential paths for recovery 2. Recognizes the signs and symptoms of trauma and vicarious trauma in clients, families, staff, and others involved with the system 3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices 4. Seeks to actively resist re-traumatization and encourage self-care A trauma-informed approach reflects a set of overarching practice principles rather than a prescribed set of procedures. These principles can be implemented across all types of settings although terminology and application may be setting or sector specific: 1. Safety 2. Trustworthiness & Transparency 3. Peer Support

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4. Collaboration & mutuality 5. Empowerment & Choice 6. Cultural, Historical, and Gender Issues In the following section, we will expand on each of the principles specified above.

Awareness of Trauma and Its Impact: Rrrrs in Action A key principle of trauma-informed care is Realization or awareness that clients may have been exposed to traumatic experiences that impact their behavior in the service setting. For example, if a client is homeless, he may have experienced physical and sexual violence on the street; he may have felt abandoned and ignored; and he may have had traumatic experiences that led to his becoming homeless. It may be easy for an unwitting, and uninformed provider to judge this client for their homelessness and treat them harshly, sometimes refusing care altogether due to lack of empathy and understanding. The nature of a client’s presenting problem (e.g., refugee status, disability, being a survivor of bullying) may suggest potential traumatic experiences that may not be disclosed during intakes. However, a client might complete a brief survey such as the ACES (Felitti et al. 1998) which can help their provider Recognize potential indicators of trauma, vulnerability to re-traumatization (based on the total score), and potential triggers (based on her history of specific categories of incidents). It is hoped that practitioners will develop increased empathy toward all clients as a universal precautions approach, particularly those with high scores, and therefore Respond by modifying their approaches (Zarse et al. 2019), which could result in avoidance of further Re-traumatization.

Safety Survivors of interpersonal trauma need to feel safe, respected, and supported in the service environment. Open, inviting and aesthetic spaces are ideal. Potential triggers (reminders of the interpersonal violence clients have experienced) should be kept to a minimum. A physical trigger may be a gun, restraints, screams, close physical proximity to a service provider or confinement to a small space. Dynamic triggers include demands for compliance, requests to disrobe, being treated as an object, or being forced to wait. In trauma-informed agencies the lighting, furniture arrangement, signs, posters, reading materials, sounds, and smells are considered from the standpoint of potential clients. If you were to imagine yourself navigating a dimly lit, confined hallway crowded with wheelchairs as the odor of disinfectant, mildew, and perspiration emanates around you. . .you encounter beeping metal detectors, large, unfriendly, armed security guards, you hear muffled screams down a nearby corridor, and notice the receptionist barricaded behind thick windows. How are you feeling right now? Now

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imagine walking through a room with multiple plants, flowers, and natural lighting cascading through large windows that allows you to take in the scenery of trees and birds outdoors. You hear soothing music piping from the speakers as well as the calm sound of water fountains and wind chimes. There is a station that offers light snacks, coffee or tea with a welcome sign. How are you feeling now? Did you notice a difference in how your body felt just by reading these two contrasting descriptions? Did one image invoke a sense of safety? Symbols likely to “trigger” a service population (such as full-length mirrors in an agency for eating disordered clients) can be minimized. Clients may be preoccupied with their safety within the agency, with the service provider, in the treatment room, and within their own bodies. These service needs may be addressed by enhanced communication. It is helpful to ask clients how safe they feel and what would make them feel more safe. Clients are encouraged to identify “hot zones” where they feel particularly unsafe and “cold zones” where they feel particularly safe as means to help service providers identify areas for potential improvement. In addition it is important to determine whether they are safe outside the service setting; otherwise, they may be distracted or their treatment goals sabotaged. For example a client may fear that her intimate partner will seek revenge after she makes a police report or inquires about substance abuse services (Sullivan 2018). Conflicts can arise between ensuring client safety and avoiding trauma triggers (such as when, following a school shooting, armed guards and metal detectors are placed at the entrance to the building). Just as hospitals have medical ethics boards that include service recipients, a team that includes members of the service population can be developed to explore these conflicts and resolve them in a way that incorporates a trauma informed response (Hopper et al. 2010).

Trustworthiness and Transparency One of the biggest challenges in working with trauma survivors is their loss of sense of trust, often due to the nature of their trauma and the beliefs they develop about the people around them as a result. Boundary violations (of the body and of personal information) are common in the histories of interpersonal violence survivors. They may find it difficult to say no when someone initiates a hug, even when it is the source of intense distress. Many survivors were conditioned to ignore their own feelings and obey their abusers. Trustworthiness requires maintaining appropriate boundaries. Clinicians take care to avoid dual relationships that can be exploitative of vulnerable populations (a source of the most frequent ethics violations for clinicians (Neukrug et al. 2001). Privacy and confidentiality are respected by trauma-informed service providers. Clients are not asked to provide personal information at a public reception desk where other clients can overhear it. Clients know with whom and under what circumstances information about them will be shared. Data collected is related to the client’s care unless (s)he has explicitly agreed to participate in research. Blanket policies, like requiring patients to completely disrobe

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or to submit for urine tests or invasive procedures, are not implemented unless necessary for their treatment. Trustworthiness is achieved by treating service recipients with empathy.

Empowerment and Choice Trauma-informed care requires a commitment to client empowerment. Survivors of interpersonal violence may have been deceived and mystified by people attempting to gain control over them; as a result they may experience learned helplessness. In trauma-informed agencies, requirements of the medical model (for individualized diagnoses and focus on deficits) are balanced with acknowledgments of client strengths. Staff highlight the bravery it took to reach out for help, actions the client has taken to survive, and the internal resources they exhibit. Maladaptive behaviors are framed as survival skills. In trauma informed agencies, clients may choose their provider, style of intervention, and time of service. Survivors may feel safer when loved ones accompany them; they may prefer a service provider of a particular race or gender (ChowdhuryHawkins et al. 2008). Transgender service recipients are given the option to use their preferred name, pronoun, and restroom facility. With non-English speaking clients, translators from the client’s cultural background are made available. Empowerment is achieved via informed consent (advanced notice of what providers intend to do and why – with the explicit right to decline services). Agencies that take photographs of clients without asking permission, collect personal data without explanation, use the bodies of unconscious female hospital patients to teach residents to perform vaginal examinations, or test clients for illegal substances without receiving consent, violate this standard. It is important for clients to know which services are mandatory versus optional, so they can decline unwanted services without being terminated by the agency (Hopper et al. 2010). When requested services are not available in house, clients are referred to agencies better suited to meet their needs (such as a secular hospital if abortion services are being considered). Clients should be treated in accordance with their unique needs. Some non-English speaking clients prefer translators who speak a similar language, but not from their country-of-origin to maintain more privacy (this may be particularly important for domestic violence or human trafficking survivors who are seeking refuge from their abusers and wish for more anonymity). A person with a disability may require specialized facilities or services (such as an accessible shelter, direct care aides, or extra time to communicate). Whenever possible, it is best to make service accommodations. When this is not possible, a trauma informed approach would include acknowledging the difficulty, validating the client’s emotions, expressing the intention to develop more specialized services, and bridging the client to more appropriate providers. Agency staff empower clients by promoting self-advocacy. The client with a disability, intellectual impairment, language barrier, or mental illness is addressed directly, rather than through a third party (such as a caregiver, spouse or parent) to the

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utmost degree possible. Agency staff explain, in jargon-free language, the contents of all mandatory forms. Questions about services, costs of treatment, or providers are answered with compassion. Agencies provide a mechanism (which may be as simple as a suggestion box) to collect anonymous client feedback and use it to improve services.

Peer Support Trauma-informed agencies cultivate trauma-informed staff by educating all employees on the importance of traumatic reactions, and ways these may manifest, among clients and themselves. Supervision, support, and feedback are provided – regardless of whether the employee provides “clinical” services. Hence, receptionists, maintenance staff, clerical workers, classroom aides, and direct care providers are included. According to the Sanctuary Model, didactic and experiential education should include: leadership training; core team training; general staff training; psycho-education for clients, families, and stakeholders; and regular booster training for staff (Bloom 1996). In trauma-informed agencies, administrators appreciate the importance of peer support and self-care in preventing burnout and vicarious trauma. Employees are given sufficient time to engage in recreation, rest and personal reflection. Attendance at agency-based retreats and off-site conferences is encouraged. Input from staff is sought before decisions are made and the goals of administration are made transparent. These actions reduce the speculation and gossip that can undermine solidarity among team members. Salaries and benefits are sufficient to minimize employee turnover (which, for clients, can trigger feelings of loss and abandonment). Evaluations and conflict resolution meetings utilize principles of nonviolent communication (McFadden et al. 2014). Efforts to ensure supervision and opportunities for postcrisis group discussion and resilience building opportunities for care providers are included as key components for decreasing risk of secondary traumatic stress (Kerig 2019).

Collaboration and Mutuality This principle highlights the importance of sharing power with consumers and staff across all levels of interaction. Collaborative treatment plans encourage clients to play an active role in decisions for their care. This includes a demystification of processes, informed by clear policies. Patients are informed of what will happen, when, why, and by whom. Providers understand that clients may have experienced challenges to their sense of power, control, self-esteem, and assertiveness; as a result they may be afraid to request clarification. In addition, a survivor who is overwhelmed and beyond their “window of tolerance,” the optimal brain/body arousal level (Siegel 1999) or unable to manage stress may experience dissociation (which impedes recall). In a trauma-informed program, clients know what their diagnoses

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are and receive written visit summaries. Specialized trauma-informed interviewing techniques with rape survivors, such as the Forensic Experiential Trauma Interview (FETI), aid in recall during police interviews; these are contingent upon collaboration and power sharing with the interviewee (Strand 2012; Rich 2019). When clients experience a sense of agency over their treatment, it can increase their motivation to continue. Similarly, care providers that have the opportunity to collaborate within and between systems particularly when promoted by leadership have a potential for increased employee engagement and decreased risk of burnout or secondary trauma and may be less likely to experience the isomorphic trauma process (i.e., helplessness, reenactment) of the survivors they are treating (Barnes and Andrews 2019).

Cultural, Historical, and Gender Issues A trauma-informed approach recognizes the impact of diversity (i.e., gender, age, ability, ethnicity, race, religion, sexual orientation, geographical location, socioeconomic status, or family system) on a client’s definition of health, illness, and healing. For example, cultural or religious differences may preclude such behaviors as shaking the hand of an opposite-sex person or telling a family member that (s)he is dying. Some cultures are family-centered rather than individualistic which may influence how trauma is perceived or should be responded to; others have prescriptive gender roles that normalize domination of women by men. Child rearing practices considered abusive in mainstream culture (like female genital mutilation) may be normative within others. Utilizing a trauma-informed lens that considers culture essentially presupposes that one is more likely to understand why a behavior has occurred and stave off harsh, often xenophobic beliefs that only create a further cycle of stigmatization, marginalization, and abuse. Providers need to be aware of how culture influences vulnerability to trauma. Rates of traumatic stress are disproportionately high among historically oppressed, vulnerable populations and cultures. Native American communities, for example, experience violent victimization at 2.5 times the amount of white communities (American Psychiatric Association 2010). Some traumas may have greater impact on particular populations because those traumas represent a significant disruption to their cultural practices or ways of life. Culture can influence which events are perceived as traumatic and how an individual interprets and assigns meaning to the trauma (Schubert 2018). Some cultures may encourage emotional outpouring, while others discourage it. For example, Chinese rape survivors may suppress painful emotions or fail to ask for help due to cultural prohibitions against upsetting – or embarrassing – the family. Trauma survivors with a Jewish background may be more likely to identify experiences as traumatic, given the cultural emphasis on historical oppression; and Italian trauma survivors may be more likely to dramatize their pain as a result of cultural emphasis on emotional expression (McGoldrick 1992; Sue et al. 2019). Trauma-informed service providers understand that culture influences how people convey traumatic stress; they also acknowledge that culture can provide strength, unique coping strategies, and specific

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resources; for example, in non-Western cultures, dance and drumming may be more effective for trauma recovery than talk therapy and medications (Leach 2015). One account with survivors of the Rwandan genocide captured this sentiment well: We had a lot of trouble with western mental health workers who came here immediately after the genocide....their practice did not involve being outside in the sun where you begin to feel better. There was no music or drumming to get your blood flowing again. There was no sense that everyone had taken the day off so the entire community could come together to lift you up and bring you back to joy. There was no acknowledgement of the depression as something invasive and external that could actually be cast out again. Instead they would take people one at a time into these dingy little rooms and have them sit around for an hour or so and talk about bad things that had happened to them. We had to ask them to leave. (Soloman 2001)

Individuals from nondominant cultures (e.g., females, disabled, LGBTQ, or African Americans, etc.) experience unique challenges when seeking mainstream services. Sensations of being an “outsider” and fear of mistreatment by authorities (typical of trauma survivors) can be amplified. Indeed, the severity of trauma experienced by LGBTQIA+ individuals by therapists and religious figures in the form of conversion therapy was notably so distressing as to warrant multiple laws and regulatory bodies to abolish the practice (APA 2018). Survivors of intimate partner violence may fear that their perpetrators will be treated unfairly by authorities (Glass 2012). Research suggests that rape myth acceptance, when an individual endorses such beliefs as “women lie about rape,” tends to neutralize violence against marginalized communities leading people to doubt, blame, or control victims, thus creating barriers with female victims’ willingness to seek services and limit the fairness by which they are treated within the criminal justice system (Rich 2019). Undocumented people may fear deportation, judgment, or violations of their confidentiality (Mason and Palvirenti 2013). Language barriers may exacerbate survivors’ discomfort and aid in mistreatment (Messing et al. 2013; Serrata et al. 2019). A trauma-informed-perspective will be mindful of service recipients’ unique cultural lens and rise to meet their needs appropriately.

Attention to Secondary Survivors It is important to recognize that trauma can do more than directly impact the survivor. Secondary survivors are people such as parents, children, spouses, and close friends of survivors who may experience their own trauma-related emotions after hearing about what happened and watching the primary survivor suffer. Secondary survivors may feel guilt at not having prevented the trauma, helplessness at their inability to “cure” the survivor, anger at the victim or the perpetrator of a crime, fearful that the traumatic event may happen to themselves or others in their circle, and/or sadness and loss. Memories of their own traumatic experiences may surface, causing them to over-identify with the survivor. Sometimes the emotions are so intolerable that secondary survivors prefer to dissociate from, avoid reminders of, or deny the reality of, their loved one’s traumatic experience.

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Secondary survivors are frequently overlooked by clinicians addressing the trauma of a primary survivor. However, secondary survivors are important foci of traumainformed care because their own trauma-related symptoms (Christiansen et al. 2012) can impact primary clients’ recovery (Ullman 2010). Secondary victims can be viewed as colluding with abusers for failing to prevent, intervene, or recognize danger for the primary client; as a result, some service providers may blame and be reluctant to engage with the secondary victim due to empathizing with the primary victim. However, secondary survivors may become allies to the treatment process by supporting the goals of therapy, reinforcing supportive messages, empowering the survivor so (s)he can regain a sense of control, and creating an environment in which survivors may heal. Trauma-informed agencies treat motivated co-victims as clients. This is accomplished by evincing sensitivity to secondary survivors’ concerns, validating their feelings, providing trauma related psychoeducation, helping secondary survivors recognize the impact of their own traumatic histories on how they view their loved one, role-playing helpful interactions between themselves and the primary survivor, assessing secondary survivors’ needs for ongoing psychotherapy and social support. Clinicians can facilitate the disclosure process when children are unable or reluctant to tell their parents about a traumatic event. In couples counseling, they can help the partner of a survivor to avoid engaging in retraumatizing behaviors (such as prematurely insisting on resumption of sexual activities following a rape or demanding to know every detail of a shameful encounter).

Organizational Structure and Culture Despite agencies’ commitment to implementing trauma-informed care principles, qualitative surveys have suggested that organizational climates need more attention in order to recognize and respond more effectively to trauma concerns. Organizational climate refers to the everyday experiences of clients and staff that reflect the true level of commitment to trauma-informed care. For example, agencies may provide sporadic training in trauma-informed care, self-care, or strengths-focused interviewing, but fail to enact these principles in everyday interactions. The Sanctuary Model, developed by Sandra Bloom in the 1980s, is a blueprint for organizational change through the creation of a trauma-informed community. Grounded in social constructivist and systems theory, it attempts to combat isolationism, rigidity, coercion, and authoritarianism in agency cultures. This is accomplished using “core commitments” including non violence, emotional intelligence, inquiry, democracy, open communication, social responsibility, and growth (Bloom 1996). A clear structure supports the functioning of trauma-informed agencies. While the value of a nonhierarchical structure has been touted, a meta-analysis of factors contributing to staff burnout and compassion fatigue among trauma workers (Prosser and Schwartz 2010) found that an unclear hierarchy, poor understanding of roles, and boundary blurring are key determinants of employee burnout and compassion fatigue. A lack of predictability can leave trauma survivors and staff feeling unsafe; hence, they may test limits and access power through informal channels.

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For trauma-informed agencies to perform at capacity, the mission statement should be widely understood. Staff should view themselves as part of a pro-social collective. Trauma-informed care as a core value should be specified in the organization’s mission statement and reflected in its policies. Staff should be able to articulate how principles can be actualized in day to day interactions (Bloom 1996; Elwyn et al. 2015).

Agency Self-assessment Agencies should engage in periodic self-assessments that examine whether, and how, basic principles of trauma-informed care are being implemented. These should include measurable input from staff, supervisors, clients, staff at partner agencies, and the public. The first stage of this process, exploration, includes clarifying the agency mission statement; identifying key stakeholders; developing a selfassessment team; evaluating the organization’s capacity for change; and seeking appropriate grants. The second stage, preparation, includes obtaining buy-in from leadership and key stakeholders; identifying outcome goals and measures; and establishing a timeline for change. The third stage, implementation, includes operationalizing (via job descriptions, training protocols, and policies), principles of trauma-informed care as they apply to the specific agency and population. This may include culture-specific interventions. The fourth stage, sustainment, includes solicitation of ongoing funding; booster training for staff; refining procedures based on input from stakeholders; and monitoring fidelity to the process. Many agencies begin at Stage 3 and fail to implement stages 1, 2 and 4; this results in greater resistance from stakeholders and decreased ability to sustain change. Periodic reviews of “red flag” events, or cases in which policies were disregarded, should be undertaken with key staff; preventative remedies should then be developed. Treatment approaches backed by empirical evidence, and expertise from specialist practitioners, should be incorporated into the procedural workings of the agency – even if this means changing established norms (Bloom 1996). Conflict resolution is an important tool for trauma-informed agencies. This is because clients have often experienced the misuse of power; in addition, conflicts among staff can, through the mechanism of parallel process, spill over into work with clients. Agencies that suppress conflict by firing or unilaterally disciplining employees create a culture where staff are unwilling to share their ideas. In a similar vein, agencies that routinely discharge acting out trauma survivors may have limited effectiveness with those who most need help. Restorative justice provides a framework to address wrongdoing in a manner that allows for self-expression, apology, making amends, and reinstatement of community solidarity. For example, if a client were to act out in a group substance abuse treatment setting, it would be up to the group to decide an appropriate means of addressing the issue and allowing the offending client a means of repairing the injured relationships while taking accountability for their actions. Research is emerging on the benefits of restorative programs

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being used in schools in place of zero-tolerance policies (Ortega et al. 2016). Agencies that employ conflict resolution strategies based on restorative justice principles may transform interpersonal conflicts into learning opportunities.

Collaboration with Trauma-Informed Partner Agencies Victims of partner violence, sex trafficking, child abuse, and rape frequently require a coordinated response among medical, psychological, victim advocacy, and criminal justice agencies. In addition, many survivors find income maintenance, substance abuse, disability, transportation, child-care, spiritual, educational, case management, and/or housing support crucial for recovery. Inter-professional teams can engage in prevention efforts, streamline referral processes, close gaps in systems and avoid service duplication. This can prevent re-victimizing experiences that leave clients feeling unsupported, abandoned, lost in red tape, stuck in repetitive loops, and triangulated. Trauma survivors who have difficulty advocating for themselves are at risk of secondary victimization by formal support staff. To prevent this, trauma-informed agencies network with safe community partners; they do not refer clients to psychiatrists, physicians, counselors, and drug treatment programs known to re-traumatize survivors. When it is necessary to refer clients to programs that are not traumainformed, administrators develop cross training programs with them in order to improve working relationships (Sullivan 2018). This is often accomplished by the use of grants that provide seed money and other incentives to develop cross disciplinary networks. It is essential that buy-in occurs at the highest levels of partner organizations and that members of interdisciplinary teams be powerful, committed and stable. Effective approaches include cross disciplinary training (education on what each partner organization does and needs); victim impact panels from the community; a case-based approach using vignettes or local examples where service gaps became evident; team building exercises; and credit universally accorded when a success occurs. Professional jargon should be translated into common vernacular. A grievance procedure should be established. There should be time for socialization before or after meetings to establish personal connections. For any success achieved, the entire group should receive credit (Lonsway et al. 2012). While teams may be challenged by status differentials, varying goals and vocabularies, and ideological differences, these collaborations are considered a best practice approach to reducing and preventing community violence.

Individual Level Barriers to Implementation Counter-Transference, Vicarious Trauma, and Burnout Working with trauma survivors can be emotionally challenging. People who hear accounts of interpersonal violence tend to visualize them. These stories can then be imagined in the form of flashbacks, nightmares, or morbid preoccupation with

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danger. People who have not been exposed to traumatic experiences may feel shocked and horrified by clients’ accounts. While staff with trauma histories may have more compassion towards survivors, they are at risk of counter transference and confusion between the client’s and their own stories. People exposed to multiple graphic accounts of cruelty, betrayal, and loss can develop preoccupation with clients, fear for their safety, relationship issues, revenge fantasies, and eating/sleep disorders (McFadden et al. 2014). In addition, they may experience vicarious trauma when their clients are harmed by other systems (Westmarland and Alderson 2013). Workers with high ACE scores and/or without adequate supervision are vulnerable to distress, acting out, boundary violations, and burnout. A perceived sense of powerless to help clients may compound these reactions. In addition, if a worker previously escaped an abusive interpersonal relationship, (s)he may assume the client can as well, despite differences in their internal and external resources. Karpman (1968) proposed the Drama Triangle, an internal working model that complex trauma survivors use to define and enact intimate relationships. It comprises three interchangeable roles: Victim, Perpetrator, and Rescuer. Trauma survivors may enact these relationships with their care providers and, through the process of projective identification, induce the latter to play complementary roles. As a result a service provider could occupy the Victim role (by allowing herself to be taken advantage of by a client), the Rescuer role (by overdoing for the client in a co-dependent manner), or the Perpetrator role (by rejecting or punishing the client). Occupying roles in this triangle can result in burnout or compassion fatigue. Typical behaviors of traumatized clients, if poorly understood, can lead to staff frustration. For example, trauma can interfere with information processing and memory, so clients may need repeated reminders of rules and requirements. Clients’ coping mechanisms (such as substance abuse, failure to budget, nonsuicidal selfinjury) may make staff feel helpless. In addition, these behaviors may be similar to those that staff struggle with or have recently overcome. Clinical supervision is useful in helping staff to identify and address these feelings, rather than acting on them (McFadden et al. 2014). Negative reactions are exacerbated when professionals work in an agency where psychotherapy and self-care are not valued; for example, first responders may not seek help with their own emotions due to professional cultures of self-reliance. Burnout can occur, resulting in cold heartedness, cynicism about the human race and desire to switch occupations. A “gallows humor” may develop in which clients are collectively mocked as a defense against feelings of helplessness and despair (Hernandez-Wolf et al. 2015).

Social Attitudes Towards Traumatized Populations According to Attribution Theory, there is a tendency for observers to place psychological distance between victims of repeated negative experiences, and themselves (Antaki and Brewin 1982). This tendency is compounded when the victims seem

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unlike themselves, and/or the observers feel unable to help. Perhaps as a result of this phenomenon, chronically disadvantaged people such as prostituted women, homeless people, undocumented immigrants, drug users, and those with criminal histories may incur derogatory attitudes. Their lifestyles and stigmatization place them at increased risk of interpersonal violence; yet they are often not perceived as deserving of services by the general public (Carbone-Lopez et al. 2015). Negative attitudes towards survivors may be conveyed through insensitive, dismissive, or judgmental comments. In stressful work cultures, where compassion is in short supply, the notion that some people deserve violent victimization can become acceptable (Levenson and Willis 2019). Justifications of harsh treatment include that if society makes jails, homeless shelters, or hospitals “too pleasant” (i.e., trauma-informed), it will encourage deviant behavior. Treatment philosophies that tout “Tough love,” “Zero Tolerance,” and “the need to hit bottom” may work against the provision of trauma-informed care (McCormack and Adams 2015). Trauma-informed staff are careful to utilize nonjudgmental language toward service recipients and hold each other accountable when such behavior arises.

Self-protection and the “Just World” Hypothesis The Just World Hypothesis (Lerner and Miller 1978) is the belief that the world is basically a safe and predictable place and that good things happen to good people (and bad things to bad people). This belief supports an individual’s feeling of safety, security, predictability, and justice in the world. Accounts of traumatic events may be difficult to hear, partly because they challenge this perception of safety and stability. Often, to distance themselves from others’ terrifying experiences, people conclude that either the misfortune did not happen, was not too painful, was predictable, or was deserved by the survivor. In order to believe the trauma was deserved, differences between the survivor and respondent are highlighted. Expanding on this, attribution research explores how people attribute blame for others’ misfortunes. Findings indicate that survivors most likely to be blamed (a) appear different from the observer (b) are victimized more than once; (c) do not conform to socially prescribed roles; and/or (d) suffer a less than catastrophic outcome (e.g., were raped but not murdered) (Antaki and Brewin 1982). Complex trauma survivors experience repeat victimization, may have unconventional lifestyles/coping mechanisms, and may differ demographically from service providers; as a result, they are at risk of being blamed by people that try to assist them (Hayes et al. 2013). Fortunately, education can help service providers identify latent similarities between themselves and their clients. Nonblaming explanations for repeat victimization (such as ongoing poverty or reframing as compounded vulnerabilities) can be presented. The harms of interpersonal violence can be emphasized, reducing the tendency to frame client misfortunes as minor. With good training and supervision, it is possible that workers who subscribe to the Just World Hypothesis may integrate new perspectives on their clients.

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Agency Level Barriers to Implementation In addition to individual attitudes and experiences, agency variables can pose barriers to the provision of trauma-informed care. Stigmatizing intake and evaluation procedures, strict service eligibility requirements, privacy violations, standardization of care, lack of employee training and supervision, laxity in hiring practices, absence of a client feedback mechanism, reluctance to collaborate with community partners, and unmanageable caseloads are characteristics of agencies that are not traumainformed. Some of the reasons appear below.

Resistance to Change Organizations typically resist change. Transitioning to a trauma-informed service delivery model may entail a radical overhaul of roles, activities, and policies. Lines of authority may change, additional roles may be developed, and relations with clients may be transformed. People who have worked to achieve agency status may fear losing it (Unick et al. 2019). Research findings that promote trauma-informed practice may appear to run afoul of “common sense,” folk knowledge, or “street smarts.” It may seem that the organization is being feminized (made more emotion focused) or masculinized (given more structure and rules) in violation of the gendered character of the occupation (Martin 2005; Nichols 2011). If insufficient effort is invested in the assessment and preliminary stages of agency transformation, resistance is likely to occur.

Cultural and Ideological Differences Some principles of trauma-informed care may conflict with the medical model. Diagnostic labels (often necessary for clients to receive services) can reify a client’s negative identity and underscore his sense of being “broken.” Individual, rather than institutional or interpersonal, deficits are highlighted. Complex trauma survivors may be viewed as manipulative and attention-seeking, their self-care strategies (utilized to attain emotional self-regulation) are often problematized (McCormack and Adams 2015). Clients may identify with their illnesses and be initially uncomfortable with an empowering approach (Davidson et al. 2010). Even within agencies designed to address trauma (such as domestic violence and rape crisis programs), ideological differences are common. Tension between the grass roots origins of these organizations and the move towards professionalization can produce role conflicts, competing directives, and unclear chains of authority (Macy et al. 2011; Simmonds 2013). For example, a domestic violence worker may try to establish a quiet, peaceful residential environment; her colleague may claim this oppresses the free expression of historically silenced women. Staff may resent the incursion of professionalization into the grassroots landscape from which feminism was spawned. Co-workers with clinical backgrounds may seem to

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imply that survivors are mentally ill – an assertion commonly employed by abusers. Some theorists contend that, due to the intersection of racial and gender oppression, those best qualified to assist survivors hail from minority cultures; others assert that partner violence is universal and demographic distinctions unnecessary. Some shelters offer classes on nonviolent parenting while others eschew these as disempowering to mothers. While research has demonstrated that counseling for domestic violence survivors can be therapeutic (e.g., Johnson and Zlotnick 2009), research on this subject is sparse and poorly disseminated. Such philosophical differences within agencies make collaboration across agencies more difficult.

Turf Issues The best way to provide care to survivors of interpersonal violence is via collaboration with community providers. However, there may be hostility among professional groups providing services. For example, religiously based agencies may not collaborate with secular organizations because of value differences surrounding sexual expression or reproductive rights, or vice versa; rape crisis agencies may compete with domestic violence programs for funding; members of interprofessional teams may disagree about issues of leadership and confidentiality; and clinicians may feel that line staff have poor boundaries. Differences in vocabulary, purposes, roles, needs, and statuses can result in poor communication. As a result, trauma survivors, many of whom hail from dysfunctional families, may be triangulated by service providers or expected to choose sides. For some, this can be re-victimizing.

Lack of Knowledge and Fear of Trauma Contagion The term “trauma-informed care is not part of the everyday vernacular of many professions. It may be viewed as the exclusive purview of mental health providers, appropriate only for severe mental illness, or as an approach to individuals but not systems (McCormack and Adams 2015). As a result of these misconceptions, it can be difficult to convince administrators of its importance. Engaging with victims of interpersonal violence is emotionally demanding (Craun et al. 2014). Some organizations may require employees to suppress their feelings and limit emotional expression by the public. Military, police, fire, and rescue organizations may de-emphasize the psychological toll faced by employees and expect workers to “tough it out.” Emotions may be viewed as indicators of weakness and inadequacy, and supervisors may feel ill equipped to assist with the emotional reactions of subordinates (Hopper et al. 2010). In addition, directors may fear that allowing emotional expression will erode the culture of the organization, as the ability of workers to remain objective will be compromised. For example, following the tragedy of 9/11, there were few members of the involved police and

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fire departments who accessed free counseling made available to them. Traumainformed agencies provide opportunities to process emotions without facing shame or negative job-related consequences (Berger and Quiros 2014).

Financial Barriers The most frequently identified obstacle to the provision of trauma-informed care is the cost. While this can be a smokescreen for underlying resistance to change, there are realistic financial investments required for agency transformation. Paid trainers, professional counselors, educational conferences, staff time off for self-care activities, and time expended for implementation can prove expensive. However, longerterm retention of clients, lower rates of employee turnover, better reputation in the community, more referrals and improved relationships/lack of service duplication with other agencies, can be seen as “payoffs” for the investment. Increasingly, grants are awarded to projects promoting interdisciplinary collaboration, cultural sensitivity, and trauma-informed care. Empirical research is needed to determine whether agencies who invest in trauma-informed approaches save money in the long term.

Workplace Bullying and Sexual Harassment Bullying and harassment are forms of interpersonal violence that resemble the battering and rape experienced by many clients seeking services. They are associated with employee burnout, absenteeism, increased use of Employee Assistance services, and morale issues (McFadden et al. 2014). Parallel process describes a tendency for interpersonal dynamics at one level of a system (e.g., between a supervisor and her staff) to be transferred to another (e.g., from staff to clients). In agencies where staff are bullied, aggression may be transferred downstream and directed at clients. Bullying and harassment reflect a lack of cultural and gender sensitivity, which are fundamental to trauma-informed work (Hernandez-Wolf et al. 2015). In agencies where these are prevalent, the effort required to become traumainformed will be extensive.

Innovations in Assessment and Treatment There have been many exciting innovations in the field of trauma-informed care. In addition, a growing number of grants require organizations to specify how they will provide services in a trauma-informed manner. This includes SAMHSA’s Mental Health Transformation Grant (which provides funds at the local, state and federal levels). In SAMHSA’s National Registry of Evidence Based Programs and Practices (NREPP), there are over 15 interventions focused on intervening with trauma. In addition, a variety of specialized measures have been developed to assess traumatized clients and the agencies that serve them. For example, a lethality assessment for

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undocumented migrants in battering relationships has been developed (Messing et al. 2013). Rich and Seffrin (2012) developed a measure of trauma-informed police interviews with rape victims. In New York, a trauma-informed juvenile court assessment evaluates daily operations with a set of benchmarks (such as mandatory training on trauma for attorneys, creation of safe spaces for youth, and addressing threats against children who testify). Goodman and colleagues (2016) developed the Survivor Defined Practice Scale to assess whether victim advocates help clients achieve self-selected goals, facilitate a spirit of partnership, and show sensitivity to their needs. In addition to measures for within-system fidelity to trauma-informed care, measures for cross-system collaboration such as Sexual Assault Response Teams and domestic violence squads have been developed. One example is Rich and Seffrin’s (2013) Collaboration with Rape Victim Advocates Index for police departments. Additional measures, and research projects utilizing these, assess how individuals respond to traumatized clients. The Social Reactions Questionnaire, developed by Sarah Ullman (2000), assesses to what extent a respondent’s behavior is consistent with principles of trauma-informed care. The Attitudes Related to Trauma-informed Care (ARTIC) scale measures to what degree staff within human service agencies value the application of trauma-informed care with their clients (Baker et al. 2015). Responding to earlier criticism of the original ACE study, the Twin Aces study (Ellis and Dietz 2017) was developed, which broadens the scope of the measure for more diverse populations by focusing on community resilience (Felitti et al. 2019). This new emphasis on strengths-based and resilience-based approaches are being integrated into various treatment programs (Garza et al. 2019a) leaving the door open for additional outcome measures to be gathered. Trauma-informed learning environments have been instituted in elementary, middle, and high schools to address individual and interpersonal problems. These include restorative justice interventions such as peer courts, restorative conferences, and community dialog circles that address harm to individuals and communities by (a) helping victims to express their feelings; (b) allowing offenders to explain their intentions/apologize/make amends; (c) reintegrate offenders into communities; and (d) allow communities of teachers, students, and parents to heal. In peer courts, student teams and their adult mentors develop consequences for violations of community standards (reflecting the principle of empowerment). Like most trauma-informed interventions, these programs are most effective when integrated into the fabric of the larger school community rather than implemented in a crisisdriven or sporadic manner (Guckenberg et al. 2016). Examples of restorative justice and trauma-informed school programs include the School-based Trauma Systems Therapy (Saxe et al. 2017) (which includes family members and multidisciplinary teams) and Attachment Regulation and Competence (ARC) programs (CollinVézina et al. 2019) for students with complex trauma histories. Qualitative studies have documented the ability of these methods to prevent suspensions, reduce absenteeism, and improve student and/or school morale (Ortega et al. 2016). In addition, these approaches may save money in the long term. The criminal justice system has made strides in providing more trauma-informed interventions, based on the principles of therapeutic jurisprudence – which states that

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criminal justice practices should result in healing rather than increased harm (Erez et al. 2011). For example, new trauma-informed approaches to crime reporting harness video and computer technology to minimize survivors’ humiliation and provide more control over the process. Some states allow emotional support dogs to accompany children when they testify against their abusers; some courts provide survivors with separate waiting rooms so they do not need to sit near the accused. Specialized drug, family, and domestic violence courts, which deviate from the adversarial model of criminal justice, have proliferated. Judges in these courts may offer encouragement and praise, treat survivors as unique individuals, provide them with a “voice” in court, and strive to rehabilitate rather than punish them. These procedures were implemented to reduce previously widespread silencing, stereotyping, and re-victimization of survivors (Lens 2017). At the federal and state levels, Crime Victims Bills of Rights allow survivors to develop victim impact statements, receive notifications about their cases, receive compensation, and access the services of victim advocates (Kirchengast 2013). Restorative justice models may allow survivors to achieve community recognition, express the impact of the assault, ask questions of the offenders, and have input into the consequences. While these goals are sometimes achieved, external power differences (such as between an employer and employee, husband and wife, teacher, and student) may limit the effectiveness of these approaches. In addition, some survivors have trouble articulating their needs and/or feel re-traumatized during conferences. To ensure that these approaches are beneficial to survivors, preparation, coaching, support, and choice are essential (McGlynn et al. 2017). Meditation, yoga, fitness, martial arts, hula (Garza et al. 2019), and dance classes are gaining increasing recognition as trauma-informed because they can assist survivors to combat dissociation, achieve relaxation, connect with their spiritual or cultural heritage, and feel empowered. However, these should be approached with caution as they may be triggering because they expose survivors’ bodies to touch, visual surveillance, body shaming, peer pressure, and domination (in the form of unequivocal directives by trainers). Mixed-gender martial arts training can re-traumatize rape survivors. As a result, there has been a proliferation of traumainformed yoga, dance, and martial arts classes that utilize single-gender facilities, gentle suggestions from trainers, requests for permission to touch, graduated degrees of immersion, and modified physical spaces/dress requirements. With greater attention to empowerment and safety, these programs allow survivors to participate in body-based interventions formerly unavailable to them.

Controversies, Questions, and Issues for Future Research In the arena of trauma-informed care, several questions remain. One is the operational definition of the term. Ideally there would be a well-validated, reliable, and comprehensive measure applicable to all settings. However, each service population is different and some client characteristics (such as mental illness or disability) create unique obstacles for implementation. For example, Rich’s and Seffrin (2012)

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measure of trauma-informed police interviews is not applicable for schools or mental health clinics. A related issue is the increasing demand for trauma-informed care credentials. Social service programs and helping professionals are increasingly likely to describe themselves as “trauma-informed” but there is no universally accepted means to ascertain this. Currently there are a multitude of training bodies and types of trauma certifications, without objective criteria for assessing comparability. Dr. Felitti (2019) has reported that when physicians administer the ACE scale, patients feel better and need less follow-up care. It is anticipated that this practice will increase empathy towards clients and facilitate the provision of trauma informed care. A remaining question is whether the use of such questionnaires may decrease staff motivation to provide trauma-informed care to all clients (the Universal approach). Additional longitudinal studies are needed to document the effects of trauma-informed care on the health and lifespans of people with high ACE scores. A newly developed ARTIC scale (that assesses providers’ attitudes towards traumainformed care) may be useful in assessing an agency’s readiness to change (Baker et al. 2015). However, scores are based on self-report data and it is unclear whether attitudes towards change predict ability to change. More research is needed in this area. It is also unclear whether adopting updated versions such as the Twin Aces study (Ellis and Dietz 2017) with its attention to resilience may be more appropriate for widespread use than the original ACE scale (Felitti et al. 2019). Questions remain about what amount of trauma-related training is appropriate for each professional group. Currently most employees refer clients with traumatic reactions/backgrounds to professional therapists. However, universal trauma education could encourage unqualified staff to practice outside their range of competency with emotionally fragile clients. For example, overzealous direct care workers could inundate their dependent clients with queries about their traumas; this could result in re-victimization. Such outcomes could be prevented by educating staff about different levels of expertise in trauma and the importance of interpersonal boundaries. There are particular clients for whom trauma-informed care is important, but not well studied. For example, clients with disabilities are at increased risk of physical, sexual, and emotional exploitation. For physically challenged clients, the structural aspects of service settings (doorways, elevators, entrances, bathrooms) and instruments of communication accessibility (TTY machines, touch talkers, etc.) are crucial. Many of these clients are victimized by caregivers, without whom they cannot survive (Plummer and Findley 2012); hence, the availability of accessible shelters and 24-h aides may be important – albeit frequently overlooked – components of trauma-informed care. There is a paucity of research on trauma-informed approaches in prisons and detention facilities. One reason is the punitive nature of these programs, combined with concerns that a hospitable environment may reward or excuse crime. In addition, clinical literature suggests that sociopaths and narcissistic personalities, viewed as resistant to change, constitute some percentage of these groups (Colins et al. 2012). For these reasons, the role of trauma-informed care for prisoners, sex offenders, and batterers is considered controversial – as is marital therapy with

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batterers and their victims. That said, sex offenders and batterers tend to have higher ACE scores, and therefore more extensive trauma histories, than members of the general population (Levenson et al. 2016; Voith et al. 2018). In addition, many incarcerated women have histories of complex trauma and can benefit from cognitive behavioral trauma-informed group interventions (Elwyn et al. 2015; RoeSepowitz et al. 2014). Partner violence perpetrators are a heterogeneous population and there are some studies suggesting that trauma-informed approaches can be successfully implemented with a subset of batterers who are motivated, free from substance abuse issues, and not personality-disordered. Cultural barriers between some service providers and mandated offenders are neither effective (Horst et al. 2012; Dworkin et al. 2018) nor consistent with trauma-informed approaches (Serrata et al. 2019). More research is needed to study the effectiveness of trauma-informed care with clients who have interpersonal violence perpetration histories. In the fields of domestic violence and sexual assault, there are debates about whether trauma-informed organizations should incorporate more egalitarian structures (Macy et al. 2011; Sullivan 2018). Long-term staff may fear that professionalization and reliance on expertise will co-opt the feminist, anti-racist philosophy upon which these organizations were based. Formerly staffed by volunteers, the agencies are now comprised of workers from differing class backgrounds and allegiances to other professions; this poses a potential challenge to workers’ loyalty towards survivors (Nichols 2011). For example, system-based rape victim advocates housed in criminal justice agencies cannot be as victim-centered (regarding client confidentiality and decision making) than those at freestanding rape crisis centers (Lonsway and Archambault 2008). Agency administrators must balance (and communicate to staff) these apparently contradictory perspectives within traumainformed institutions. Some definitions of trauma-informed care (e.g., that utilized in restorative justice) emphasize the importance of community involvement as a core aspect of healing. In this paradigm, rape and intimate partner violence survivors participating in “walk a mile in her shoes” and “take back the night” rallies not only give to the community but experience a personal benefit; similarly, war veterans heal through involvement in memorials and parades. A part of the benefit is consciousness raising, both of the community and of the self in recovery. However, this definition is not universal: Wilson et al. (2015) found that while many trauma-informed domestic violence programs have similar goals, some adopt a more individualistic stance. While positive effects of altruism and participatory action on survivors have been documented, the field is divided on whether this is an essential aspect of traumainformed care (Macy et al. 2011; Sullivan 2018). Despite ongoing questions and challenges, the field of trauma-informed care is expanding rapidly. This represents a leap in human understanding about the causes and consequences of trauma and will pave the way for a more just and compassionate society. There are many opportunities for researchers to collaborate with clinicians and agencies to advance our understanding of trauma informed care which may give a more robust outlook on the needs of survivors and institutions, but also put an onus on collaborators to break through from their established silos and may cause

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discomfort in the process. However, taking a cue from social justice advocates that understand challenges with shifting cultural views, a little bit of discomfort can keep us on our “learning edge” and yield positive results (Arao and Clemens 2013).

Key Points 1. Although it may go undetected, trauma is widespread among the populations of clients that we serve. 2. Secondary survivors are also affected by trauma and may require intervention. 3. Trauma informed care can be used to improve services, percent of staff burnout, and reduce re-traumatization of clients and staff. 4. Safety and respect; empowerment and demystification; attention to issues of cultural diversity, individualized treatment plans; respect for client privacy; collaboration with other trauma-informed agencies are components of traumainformed care. 5. There are many individual and institutional barriers to the provision of traumainformed care including resistance to change, lack of understanding, fear of emotional contagion, concern about costs, negative attitudes towards the unfortunate, and cultural barriers. 6. Innovations in Trauma-Informed practices emphasize strengths-based and resilience-focused approaches, restorative justice, and alternative forms of creative expression that incorporates use of mind/body strategies. 7. Research remains to be done on development of measures, dissemination methods, markers of success, best practices for implementation within specific settings, training protocols, and the value of universal versus individual approaches.

Summary In this chapter, we explored concepts of trauma-informed systems of care within the context of interpersonal violence. We outlined the basic definition of trauma and ACES, their impact on health, and related principles of TIC: Safety, Trustworthiness & Transparency, Peer Support, Collaboration & mutuality, Empowerment & Choice, and Cultural, Historical, and Gender Issues. We also highlighted the importance of adopting TIC approaches into various systems of care to better serve both service recipients and care providers, with the ultimate goal of (1) realizing the impact of trauma, (2) recognizing the signs and symptoms of trauma, (3) reducing the physical, psychological, and social impact of trauma, and (4) reducing the risk of re-traumatization. We delved deeper into each of the TIC principles by exploring some of the obstacles often faced to implementation of best practices from both an individual and institutional level such as countertransference, burnout and vicarious trauma, social beliefs, endorsement of flawed beliefs in a Just World, resistance to change, cultural and ideological differences, turf issues, lack of knowledge and fear

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of trauma contagion, financial barriers, as well as workplace bullying and harassment. We also explored some research initiatives in the field in effort to guide safe, compassionate, and respectful service delivery across all systems of care. Many of these new trauma-informed innovations involve improved assessments, and methods of service delivery that rely on strengths, resilience, restorative justice opportunities, and incorporation of mind and body strategies that have historically not been widely embraced by western practitioners. We conclude with a discussion of the controversies and questions being posited in the field regarding measures and dissemination practices and offer future directions for research. It is our hope as researchers, practitioners, and advocates that we will 1 day view the trauma-informed world we envision and have the opportunity to experience a life free of interpersonal violence.

Cross-References ▶ Addressing Intimate Partner Violence Within the Healthcare System ▶ Adverse Childhood Experiences: Past, Present, and Future ▶ Child Survivors of Intimate Partner Homicide: Wraparound Intervention ▶ Implications of Maltreatment for Young Children ▶ Mental Health Treatment in the Context of Intimate Partner Violence ▶ Overview of Child Maltreatment ▶ Stigma and IPV Victimization ▶ The Contemporary Study of Adult Survivors of Interpersonal Violence and the Development of Mental Health Treatment ▶ The US Mental Health Care System’s Response to Intimate Partner Violence: A Call to Action ▶ Treatment of Post-traumatic Stress Disorder in Survivors of Intimate Partner Violence

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Intersectionality Sujata Warrier

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Historical Origins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practical Implications of Intersectionality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Implementing Intersectionality in Everyday Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

The ideas embedded within the concept of intersectionality can be traced to the speech given by Sojourner Truth in 1851. It was coined by Kimberlé Crenshaw. Intersectionality is not only a theoretical tool but is necessary for justice, advocacy, interventions, and policy development. It enables us to move away from single axis and binary thinking that have long hampered social justice movements and practical work with individual members of a marginalized community. Intersectionality provides the necessary grounding that enables all intervenors to acknowledge the multiple identities and institutional structures that disempower people from historically and current marginalized communities. Within the context of practical work, it is important to go beyond a simple analysis that focuses primarily on any one aspect of identity as the explanatory factor to exploring the multiple types of discrimination. Exposing the convergence of different types of discrimination is necessary for individual work as well as in areas of research and public policy. This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. S. Warrier (*) Battered Women’s Justice Project, Minneapolis, MN, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_301

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Keywords

Intersectionality · Identity · Oppression · Privilege · Gender-based violence · Patriarchy · Power · Commonalities · Differences · Advocacy · Activism · Policy · Survivors

Introduction Historical Origins There is a growing and steady awareness of the term intersectionality in many different movements, spaces, academia, and among activists. However, it remains confusing both as a term and the implications for application. Prior to it being coined by law professor and activist Kimberlé Crenshaw (Crenshaw 1989), the ideas encompassed within it were in circulation among activists and scholars from historically marginalized communities (Combahee River Collective 1977; Moraga and Anzaldua 1983) and in Sojourner Truth’s 1851 speech “Ain’t I am Woman?” where she spoke from her position as a slave (Truth 1851). The focus of many of the discussions among feminists of color during the 1970s was on diversifying early feminist thinking to include concerns of race and class. The emphasis was on the inclusion of ideas now contained within the concept of intersectionality and challenging white feminists who were focused on solidarity based upon the notions of a common sisterhood. The anthology This Bridge Called My Back (Moraga and Anzaldua 1983) had a major impact on feminist thinking both in academia and activist organizing because it linked race, class, gender, and sexuality in ways that had not been done before. Its legacy is embedded in the term intersectionality, and much of the current thinking and usage owes a debt to the early work done by feminists of color. Intersectionality is an analytical framework that has useful implications for work in different areas. It assists in understanding how different aspects of social and political identity (race, class, gender, ableism, sexuality, etc.) combine with each other in unique ways to create diverse modes of discrimination and oppression. The idea is linked both historically and theoretically to the notion of “simultaneity” articulated by the Combahee River Collective (Combahee River Collective 1977). Simultaneity refers to the simultaneous ways in which race, class, and gender, as well as other dimensions of identity, impact the lives of their members and their resistance to oppression. (Originally, the idea of intersectionality encompassed the markers of race, class, and gender. These are the three markers of identity that Crenshaw expounded upon. Since the 1990s, the idea of intersectionality has not only transcended internationally, but it has expanded to include other markers such as sexual orientation, age, geographic location, able-bodiedness, immigration status, language, and others. It is important to remember that these are categories created in order to understand the markers of difference; hence they are all contested terrain and the significance and meaning of each change as more knowledge is acquired.) This

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was a challenge to both the emerging feminist movement and the Black male-led social movements for civil justice. Crenshaw picked the simultaneity theme to highlight the marginalization of Black women both in the areas of anti-discrimination and in feminist theory and politics. In the crucial 1989 paper (Crenshaw 1989), she argued that the experience of a Black woman could only be understood when race and gender as categories were seen as interacting and reinforcing each other and not separate. Through this argument, she challenged the existing feminist idea that only gender determines a woman’s fate. Two years later (Crenshaw 1991), she refined the concept in order to highlight the very specific ways in which experiences of immigrant, Black, and other disadvantaged communities were marginalized within the social justice movements and particularly in the movement to end violence against women. Her work can be used to understand the ways in which historical oppression impacts the lives of Black women. In her work, Crenshaw identifies three aspects of intersectionality: structural (how violence can be qualitatively different for marginalized people), political (laws and regulations that have differential impact), and representational (in media and culture). All three are critical in grasping the lived experiences of people from marginalized groups. Patricia Hill Collins (2000) further developed the ideas into examining how patterns of oppressions are not only interrelated but bound together. Since the publication of these articles, there has been tremendous debate as to whether the concept has any practical implication. It must be emphasized that originally the focus was on providing a theoretical and analytical framework for appreciating that all marginalized peoples do not face the same levels of discrimination and that their lived experiences reveal a great deal of juggling in order to survive. Many movements and disciplines have pushed the analysis and applications. The result is the crossing of intersectionality into international territory as well as constant adaptation, contestation, and change. The appeal of an intersectional analysis lies in its ability to increase awareness of how interconnected experiences based on identities can contribute to unique experiences of both oppression and privilege.

Practical Implications of Intersectionality Intersectionality may appear to be all theory. Given the origins and even Crenshaw’s formulation, it is meant to be used practically. There is an activist strand that lies at the root of the usage of intersectionality. Many of the early contributors to the thinking on intersectionality have attempted to integrate the concept with organizing efforts in various communities that expose the diverse experiences of power. Critical to organizing across differences is to think in new ways of the meaning of power, oppression, and discrimination in order to transform organizing itself and to affect policy change. Early efforts were focused on gender, sexism, and misogyny and the exposition of power as being both pervasive and specific simultaneously. These thinking allowed women, in particular, to come together, unify, and discover common threads but to also maintain specificity when needed.

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Intersectional analysis and implementation found the perfect site of work in violence against women (VAW). As the fiercest expression of gendered oppression, VAW gave ample opportunities for activists to explore both the specificity of its expression in communities and the pervasiveness of the problem. It led to some of the most grounded analysis on the structure of power that is leveraged against women but also the ways in which power can be used to resist and build powerful alliances among women. Vast numbers of practice as well as policy issues were tackled transnationally in organizations as well as governmental agencies. The many decades of work on violence against women were helpful for other social justice movements. As a result, intersectionality is considered critical for all work that aims to build social equity as our understanding of the complexity of lives increases. Without the intersectional analysis, movements’ practices and events that address injustice toward any one group may end up perpetuating inequity toward another. For example, in work with survivors of violence against women (VAW), an intersectional lens has enabled practitioners to work with survivors in exploring all possible consequences of engaging with systems that may lead to unforeseen consequences: homophobic response from the criminal legal system may deter those who are either gay or lesbian with added challenge if they are poor or from a community of color. The intersectional lens enables practitioners to approach access to resources using the intersections of all markers of identity and not just assuming that survivors are a homogenous lot. In the international arena, work on the issue of poverty has historically focused only on class issues. Working with poor women has taught development professionals that focusing on class alone or gender alone does not assist in empowering poor women. Additionally, they have to also consider other markers in specific societies that may make it harder for some women to access credit or even work in the informal sector. Utilizing an intersectional lens has enabled practitioners to build programs that address multiple issues simultaneously leading to better practices. While intersectionality is being continuously refined, challenged, and reworked, it has not only moved into other disciplines and areas of work but also crossed national boundaries into the international arena. Transnational work has focused on revisiting the formulation of international policies and practices that are interpreted narrowly along a single axis of identity and discrimination. Rather the attempt now is to have more contextualized interpretations of global equality provisions. Intersectionality, therefore, is not just an analysis of difference as marked by identity but is also an analysis of power, privilege, and oppression. It is not just an academic exercise but has been applied to addressing social inequality because identity does not stand apart from the structures and relations of power. Therefore, social justice concerns are fundamentally embedded in intersectionality. To divorce unjust systems of power from intersectionality is to reduce it to a heuristic device and loose the very foundation on which it is based. In practice, most disciplines emphasize the need for a holistic understanding of the breadth and depth of human experience. The need for capturing the complex

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lived experiences of an individual within family, community, and society is necessary to order to empower individuals and promote social justice. Intersectionality captures the holistic breadth of an individual’s experience in the matrix of social relations of power and frame social divisions as expressed by Yuval-Davis: “Social divisions are about macro axes of social power but also involve actual, concrete people [micro axes]. Social divisions have organizational, intersubjective, experimental and representational forms, and this affects the ways we theorize them as well as the ways in which we theorize the connections between the different levels. In other words, they are expressed in specific institutions and organizations, such as state laws and state agencies, trade unions, voluntary organizations and the family. In addition, they involve specific power and affective relationships between actual people, acting informally and/or in their roles as agents of specific social institutions and organizations” (Yuval-Davis 2006, p. 198). The analysis shifts from a liner, binary, and one-dimensional approach toward an individual to a more complex, dynamic, and contextual approach to understanding lived experiences. This requires us to think differently about identity, equality, and power and a critical examination of access to rights and opportunities. The eradication of oppression and discrimination is ingrained requiring a substantial investment in analysis and implementation. Secondly, intersectionality values a “bottoms-up” approach in that we begin by asking questions about the lived realities of people. The picture is then built upward accounting for all the ways in which systems and power impact specific individuals. Personal narratives are combined with disaggregated data to reveal specific and common impacts of policies and practices. For example, when analyzing the impact of poverty, it is not enough to just know that poverty has severe impacts on people. Differences between men and women have to be acknowledged as much as the differences between diverse bodies of men and women. When we consider the link between poverty and domestic violence, there is clear acknowledgment in research that the relationship between poverty and violence is complicated and reciprocal. (Over the last few decades, the terminology in the area of gender-based violence (GBV) has grown and changed to encompass differences in approach, orientation, and academic discipline. When the movement to end violence against women (VAW) began, the specific reference was to battered women. When families were included, the terminology shifted to family violence (FV) or domestic violence (DV) or specifically intimate partner violence (IPV). VAW also shifted to GBV with the recognition of violence in same-sex relationships. Each of these areas is minefields of arguments which cannot be covered here. I use them interchangeably as I do the term victims and survivors.) While poverty is not the cause of domestic violence, it exacerbates the intensity and severity of the violence along with access to resources and safety for the survivors and accountability for offenders (Wilcox 2006; Slabbert 2016; VAWnet 2020). The work has also focused on geographic location and variations in the levels of poverty. It is this complicated examination that reveals the specific ways in which policies and practices have a differential impact on different groups of men and women.

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Implementing Intersectionality in Everyday Practice The history of the adoption of intersectional work is a reflection of how thinking impacts our response to individuals as well as working on addressing social inequalities: 1. Recognizing Multiple Intersecting Oppressions: An intersecting approach recognizes that there is systemic and systematic discrimination due to race, gender, class, etc. The intersecting nature of any of these categories creates power dynamics between individuals, families, and communities. Situating oneself in the matrix of power, domination, and oppression is the first step to recognizing of how these impacts work with individuals. Which narratives do we pay more attention to? Why? Who are the most marginalized in the community and which programs are available to them? What role does inequality and everyday experiences of oppression play in an individual’s response to intervention? Who has control and can dictate engagement with systems without repercussions? What level of engagement works for whom and under what circumstances? Power is contextual, relational, and unequal and is very present between an interventionist and an individual. The power differentials have to be considered even if the intervenor is from the same community as the individual. Intersectional analysis acknowledges both inter- and intra-community differences; in fact, it is one of the few theoretical frameworks that examines the intra-community diversities as a critical factor in how oppressions manifest in similar situated individuals and communities. So, for example, on the face of it, Black Lives Matter (BLM) appears to be a movement that focuses only on the lives of Black people, in particular young Black men and police violence. However, a closer examination of the work done by BLM reveals that from the beginning, founder Alicia Garza focused on the ways in which policing affects not only Blacks but other people of color including undocumented immigrants, Black queer people, and others (BLM 2020). In the area of sexual violence and the #MeToo movement, founder Tarana Burke focused early on the specific needs of survivors of sexual violence among poor Black women. Within a few years of starting the work, she realized that a more intersectional approach that addressed the intersection of race, class, gender, sexual orientation, and disability was critical to empowering survivors across differences (MTVT 2006). 2. Centering Voice of the Marginalized: The voices of those most impacted by the intersection of oppressions are the ones most left out and excluded out of the discussions. The narratives and stories that they have to share should be the ones that are promoted and uplifted to guide not only individual work but also any organizational or policy change that may come about as more intersectional work is done in agencies or organizations. Impacted communities and individuals within those communities should have the capacity to have a voice in any change in policy that will directly affect them. Much of the earliest work on centralizing the voice of the marginalized can be traced to the work of bell hooks in her classic Feminist Theory: From Margin to

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Center where she argues for centering the experiences of Black women whose lives have always existed on the margins of both American experience and feminist theorizing (hooks 1984). Similarly, it was victims-survivors who created and led the movement to end violence against women during the early years of its formation. Guided by them, US society was to witness many changes in the area of service provision, public policy, and legislation (Schechter 1982). Success and too much of a focus on system response led to the decentering of victim’s voices, especially those from marginalized groups. However, with the rise of BLM and the MeToo movements, a refocus on victim needs and centering the voice of the victim, especially those from historically oppressed groups, has re-envisioned the movement and services (Koss et al. 2017). The work of the East LA Women’s Center has been creating and centering the voices of the marginalized. They recognized early on that their work to support survivors of sexual assault in their communities had to examine and design programs that included the complex intersections of HIV/AIDS prevention for Latina and Black women, support for poor communities, and utilize community mobilizing models, such as the Promotoras Program that built expertise and champions’ local community leadership (CALCASA 2017). Therefore, centering the voice of the marginalized includes always asking: Who is included in program design, case work, and organizational culture? Who is not included and why? Who is most impacted and how do we include them? 3. Being Inclusive: The above questions also lead us to the need for being inclusive in all areas of case and social change work since there is no one single or universal experience of oppressions. In working on and dealing with the issue of difference, the attempt has been to start from a universal and attempt to fit in differences or treat them as aberrations. The historical problem has been that the universal has always come from the perspective of the most privileged and those with the most power. Their experiences have driven the narratives in almost every academic field, advocacy work, and activist organizing. Ideas around intersectionality evolved to change that perspective and to force the inclusion of other narratives. In the area of the movement to end domestic violence, recent focus has been on examining the link between which group of victims are impacted most by unjust systems and structures and then ensuring that their voices and issues are being included and prioritized in the work. So, for example, if in a specific jurisdiction trans-survivors who have mental health problems are the most impacted, case and policy work has to include their voices and ensure that their concerns are prioritized. In developing any victim-centered policy, voices from the affected communities have to be centered. This means that if we do the work from an intersectional lens, we accommodate intragroup differences and ensure that contradictory voices are heard. In terms of service provision, this may mean that a standard menu of services may not work for everyone in a specific community. Calling the police for assistance may be anathema for some survivors from an immigrant community but may be an option for others. Inclusivity means providing a plethora of choices that may be appropriate for some victims some of the time under certain contexts. This means that there should be a traditional

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menu of services offered for victims of IPV and sexual violence along with the option of non-traditional services as such as restorative justice work. In all cases, victim safety should be at the forefront of the work. The gift of the work from the driving force of intersectionality has been the perspective that there are both inter- and intragroup differences. Sometimes, intragroup differences are sidelined because intergroup differences are highlighted. Power differentials within groups can also drive the suppression of narratives that are not aligned with dominant themes. But doing intersectional work and inclusion requires that attention be given to narratives that do not follow dominant ideas. This means that there are multiple voices and experiences: all “Asian women” do not experience gender and racial oppression in the same manner. While there may be common themes, it does not mean that all narratives will be identical or even similar. Variations and multiplicity can surface because of age, class, location, orientation, and length of time they have been in the USA as well as immigrant status. The multiplicity of voices and stories has to be heard in order to make change lasting and applicable to a wider group of people. Oftentimes, this is where movements and case work have not ensured that we hear from those who may not be in agreement with the prevailing ideas of assistance. Similar concerns are “Who has control of these narratives and stories?” and “Who tells the stories and how is it getting heard and by whom?” Inclusivity requires that analysis includes how power and privilege of the observer impact how the narratives are being heard and what elements are retained and why. The position of individuals located in larger hierarchical institutions of power, their own representations in the dominant discourses, impacts both the type and quality of care provided to those who do not belong to and whose lived experience differs considerably. Care of any sort focuses on a dyadic interaction between two parties and an understanding of power and privilege that play out in the work; however there are institutional structures of power and hierarchies that shape the work and have to be taken into consideration. Intersectional work requires the consideration of an analysis of power and privilege at the personal and the institutional levels that shapes any dyadic interaction between individuals working clinically or in the capacity of an advocate (Baker and Bevacqua 2018). Checking to make sure that one is being inclusive in programing, services, and projects does not have to be tedious. A fairly consistent regime of simple evaluations and questions such as: What worked and why? What did not work and why? What could have been done differently? What adjustments and changes are required now? (Luther College Intersectionality Toolkit 2014, p. 22). 4. Remember the Activist Roots of Intersectionality: No matter the professional affiliation and knowledge that an intervenor has, the activist roots of the origins of intersectionality have to foreground any clinical work. Activism and organizing have been the driving forces of the later incorporation of it into academic and clinical work. This translates into not only intersectional case work but utilizing knowledge from narratives to organize for change in social relations and

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oppressive structures. Nurturing the capacity of those impacted by historical oppression to fight for change is part of social justice work and has to be part of any advocacy or clinical work. The concept of intersectionality has been utilized in many areas, and people have struggled to make it more practical; it is about changing hierarchical social structures for a more equitable distribution and access to resources. Consistently, checking in with community and building collaborative relationships with members is critical to maintaining the activist roots. Community connections amplify the needs and access to opportunities for all members even those most marginalized. In the end, intersectional approaches to survivors of domestic violence, for example, are about organizing and activism in order to bring about justice for all victims. 5. Intersectional Programing and Case Work: Intersectionality and an understanding of the history and the current manifestations of all form of oppressions are a must. Knowledge of all the isms and their intersections is necessary and fundamental to any program design and individual work. For example, The Sex Workers Project, of the Urban Justice Center in New York City, designed their program to address sex worker rights, human trafficking, health, immigration, policing, and LBGTQ issues. Their direct service work addressed the needs of immigrant sex workers in a comprehensive manner (Sex Workers Project 2018). Case work must be anchored in this analysis and driven by the needs and understanding of the location in the matrices of oppressions. It is also essential to locate oneself within the same matrices to understand how power and privilege shape one’s own assumptions, biases, and prejudices. They impact individual case work and the manner in which one listens to narratives and stories. Individual case work relies on listening to and attempting to understand the story that is being shared. It is critical to remember that the listener is being granted the privilege of hearing the story and that there is an oral exchange between two people (DasGupta 2014). It requires the listener to absorb, acknowledge, interpret, and act on the story (Charon 2001). But such actions need to be done with humility and the recognition that there are many parts to the story that are not knowable and not shared. It is through the sharing of the stories that an exchange is created between the listener and the story teller. This exchange often mirrors the hierarchies in society, and it behooves the listener to be critically self-aware as to how they enter the space of the narrative and to continuously monitor and evaluate as to how they are absorbing parts of the story, what acknowledgment is being provided, recognition of the ambiguities and contradictions within the stories, ways in which interpretation is occurring, and then what actions are being taken. It is important to remember that as the listener, we do not own the story. Intersectionality and: “Narrative humility means understanding that stories are not merely receptacles of facts, but that every story holds some element of the unknowable. It simultaneously reminds us that there are larger sociopolitical power structures that marginalize certain sorts of stories and privilege others. Narrative humility suggests an inward orientation, requiring not only that

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we learn about others, but that we begin by learning about ourselves—how our past cadre of life stories has built our prejudices and preferences, and how by the very act of listening, we ourselves are always changed into different kinds of listeners” (DasGupta 2014).

Arrogance arising out of years of experience working with victims of either sexual or domestic violence can get in the way of truly listening to and understanding the specificity and uniqueness of an individual’s story. In working with victims, work has to be guided by critical self-interrogation that locates oneself in the matrix of power and domination and is guided by an intersectional victimcentered approach. 6. Public Policy, Organizational Culture, and Social Change: Individual case work while critical is not enough. Intersectional work requires us to also engage in public policy and social change work. The individual is connected to the larger structures, and if we have to change the narrative of the marginalized, then engagement at the policy level is important in order to redistribute access to resources and change the dominant paradigms. Collaborations with both likely and unlikely partners are key ingredients. Engagement with them from the beginning and the introduction of multiple contradictory voices is essential so that intersecting and cross issues organizing can occur. For example, focusing on just criminal justice issues is not enough. These issues can have an impact on health, and health can be impacted by class and race. Consideration of the connections between these issues that appear disparate is integral to understanding unintended consequences. Promoting social justice and opportunities for the marginalized needs very deliberate and methodical considerations. In order to achieve these considerations, organizational structures, institutional hierarchies, and analytical thinking within these have to be critically evaluated. Organizational structures that stifle change require a broad commitment at the institutional and corporate level strategic planning. Both conceptual thinking and a deep commitment to want the change are necessary. All stakeholders within an organization have to be involved in order to change entrenched power dynamics within an organization in order to work toward social and public policy change. Public policy, as designed currently, often impacts how people end up viewing themselves because of the ways in which services and resources are distributed to people. These decisions are often made by governments without a great deal of input by those who are on the margins of society. The use of an intersectional lens provided by public policy scholars in collaboration with community members, activists, and service providers can challenge the “rational self interest lens” (Manuel 2006, p. 192) that often guides public policy. Having enough people from communities most affected is a must at many of the convenings where concerns are aired and decisions made and power used for social empowerment rather than a as a tool of domination (Crenshaw 1991). An intersectional lens forces public policy to move away from (a) simple analysis and solutions to more

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complicated and multifaceted; (b) it may be more time-consuming and costly in the short term but over less expensive over the long term; (c) work collaboratively to capture the broad range of people’s experiences; (d) communicate clearly to understand the specific needs of constituents including contradictory opinions within communities (Manuel 2006, pp. 193–196). “In more simple terms, good public policy takes stock of where people are located, where they want to be (the goodlife), and how the good society can build bridges to help them get there” (Manuel 2006, p. 196). Intersectionality is, therefore, not just a feel good academic concept but requires change at all levels in order to bring about meaningful change.

Key Points • Intersectionality is an analytical framework that has critical implications for practice, program development, and policy work. • It allows practitioners, activists, and advocates to critically engage with the ways in which power, privilege, and oppression connect and interact. • An analysis of the intersections of power and one’s location in the matrix of domination leads to continuous critical self-awareness as the first step. • Victim-centered approach is an integral part of intersectionality and requires moving away from “all survivors are a homogenous group” to recognizing the uniqueness of survivor experiences that arise out of the intersections of different oppressions. • Clear analysis and understanding of the intersectional context are necessary to ask the right questions and inform case practice and advocacy. • Acknowledging inter- and intragroup differences leads to a more robust understanding of commonalities arising out of the intersections of oppressions. • Using an intersectional lens forces us to listen to narratives and stories with humility. • Advocacy, public policy work, as well as activism that have an intersectional lens are necessary for all social change work.

Summary and Conclusion Intersectionality, today, has a robust history that crossed transnationally and is used in many different spheres and academic disciplines. It continues to emerge as an analytical and pragmatic tool to bring about social change. Over the decades, it has undergone many intellectual and theoretical formulations and changes. The potential it presents is not utilized to its fullest capacity. At this juncture in time, it is absolutely essential to incorporate intersectional work at all levels. The use of stories and narratives of struggle, resistance, power, and cooperation from those on the margins is needed for making social justice and equity central to theme of social justice and any work with victims of either domestic or sexual violence.

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Historical and Contemporary Racial Trauma Among Black Americans: Black Wellness Matters Gimel Rogers and Thema Bryant-Davis

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . America, Free of Africans: Considering Contributions of Black Psychology . . . . . . . . . . . . . . . . . Historical and Contemporary Racial Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Historical and Contemporary Racial Trauma Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Power and Control Wheel of Historical Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physical Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sexual Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Systematic Resource Denial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Economic Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appropriation of Cultural Resources, Traditions, and Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . Spiritual Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Race Socialization Via Cultural Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychological Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Long-Term Effects of Historical and Contemporary Racial Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Applications when Working with Black Americans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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*In this chapter, Black and Americans of African Descent are used interchangeably. This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. G. Rogers (*) F.I.R.E. Igniting Lives, San Diego, CA, USA e-mail: Drgimel@7fire8.com T. Bryant-Davis Pepperdine University, Los Angeles, CA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_338

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Abstract

Racism has existed in the United States since its inception, causing negative physical and emotional consequences. This chapter will explore the significance of addressing Black mental health concerns, while detailing the ongoing realities of anti-Black racism systemically and individually. Taking a decolonizing approach to psychology, it will provide a brief overview of the contribution of Black psychology, and then discuss historical and contemporary racial trauma inflicted on African descendants living in America. Examples of racial trauma will be provided, and long-term effects will be discussed to support the call for culturally responsive clinical applications. Keywords

Historical trauma · Societal trauma · Racial trauma · African Americans · Black · Violence · Racism · Oppression

Introduction Trauma mental health professionals operating from a Western psychological framework have often discounted the traumatic nature of oppression (BryantDavis 2019). Western psychological perspectives (i.e., Euro-centric) attend to the decontextualized trauma survivor, routinely ignoring socio-political power, privilege, and injustice (Goodman 2015). In contrast, a social justice oriented trauma perspective adopts a social ecological framework that incorporates context and systems which directly and indirectly threaten the survival and well-being of racially marginalized survivors. When listing types of trauma, trauma psychologists trained in predominantly or exclusively White American trauma models will acknowledge the trauma of: (a) sexual assault, (b) child abuse, and (c) school shootings of individuals but systematically ignore the (a) mass terror, (b) torture, (c) enslavement, (d) colonization, (e) disenfranchisement, and (f) even genocide of entire groups of peoples. This chapter counters this biased, racist approach to the study of trauma and instead calls for a recognition of oppression, with a special focus on racially motivated historical trauma and the trauma of contemporary anti-Black racism. Societal trauma, also known as the trauma of oppression, takes many forms including but not limited to racism, sexism, heterosexism, classism, and ableism. This chapter will focus on anti-Blackness racism as a historical and contemporary trauma deserving of attention and redress. Arthur Schopenhauer once penned, “All truth passes through three stages: first, it is ridiculed; second, it is violently opposed; and third, it is accepted as self-evident” (n.d.). The humanity of Africans in America has been ridiculed, violently oppressed, and now it is time for it to be accepted as self-evident. This country was built on

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Black people’s labor, disenfranchisement, torture, and State sanctioned traumatization. Enslavement, segregation and present-day institutional racism begs the question: “Are we in the land of the free?” This chapter will explore that question and illuminate the need for trauma mental health professionals to learn ethical and appropriate responses to survivors of racial trauma, including but not limited to Black Americans. It is noteworthy that Blacks who are not of American nationality also suffer from racism in America. It will provide a brief overview of Contemporary Black psychology that is rooted in African Cosmology. Next, it will discuss historical and contemporary racial trauma inflicted on African descendants living in America using the Power and Control Wheel of Historical Trauma. Each portion of the wheel will be highlighted in a part of the chapter by describing various manifestations of each form of racial power and control. After this foundation is provided and long-term effects of racial trauma are characterized, the chapter will conclude with interventions and assessments that may be useful to mental health practitioners as they take steps toward racial equity with their clients.

America, Free of Africans: Considering Contributions of Black Psychology Imagine the condition of America without Black minds, Black labor, and Black artistry. Ralph Ellison, author of Invisible Man, revealed how Black people have affected America materially, psychologically, and culturally through his article What America Would be like Without Blacks (1970). The vast contributions of Black Americans to American music, politics, religious institutions, science, art, and technology are undeniable and yet these transformative additions are not routinely taught in primary or secondary education. Despite these deficits in the U.S. educational system, some people have educated themselves about the numerous and invaluable contributions of inventions to American society from people of African descent, but few have knowledge about the ancient African contributions to the field of psychology. Usually if people are asked to name famous African Americans, they name Civil Rights leaders, athletes, or musicians. The contributions of people of African descent to scholarship, including psychological sciences, are less known. Contemporary Black Psychology is a re-ascension of the very first psychology, dating back to the Nile Valley civilization of Ancient Egypt. The original psychology is a part of the African cosmology, traced to the time when the Blacks of Africa produced an organized system of knowledge, including knowledge of the human mind. Likewise, to comprehend the collective impact of anti-Blackness racial trauma, one must obtain a sense of the lives, contributions, and creations of people of African descent prior to colonization and enslavement. Any study of trauma recognizes the importance of assessing the individual survivor’s pre-trauma functioning. According to scholars (Nwoye 2015), the primary descriptors of the ancient African worldview are as follows:

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1. There is no mind/body duality as there is emphasis on the whole of human organism (i.e., body). 2. Every human is endowed with a supreme life force in that God is in the details of the human experience. 3. Emotionality is a necessary form of life. 4. Collective survival is being a part of a group. 5. A great respect for the spoken work as oral histories is vital. 6. Time is characterized by past and present and it is not determined by numbers. 7. A harmonious blending of the material and spiritual is emphasized for wholeness. 8. A special appreciation for the elderly is a key characteristic. 9. Strong religious faith is an identifiable component. 10. Self-determination is part of defining and creating ourselves. 11. Music and the arts are forms of expression. 12. Exploring the life cycle requires consideration of conception, birth, naming ceremony, puberty, initiation rites, marriage, adulthood, old age, and immortality. Among the many other systems created by Nile Valley civilizations, Kemetic culture constructed Sahku, a system of knowledge which encompassed dimensions of the soul, mind, psyche, conscious, unconscious, and human transformation; it was designed to study human illumination and the ultimate state of human development (Nobles 2015). Thus, understanding the individual is appreciating the collective. The violence and destruction that assured an effective system of colonization and enslavement resulted in a disruption of culture, family, language, values, and freedoms, among several other inalienable human rights. The prejudice and discrimination that persisted well after slavery induced laws of segregation, lynching, burnings, and restrictions on voting and other civil rights, which have hindered opportunities for Black people. Black psychology, which is a form of decolonized psychology, recognizes that trauma recovery cannot stop at the point of coping but also includes resistance of racial trauma (Bryant-Davis and Ocampo 2006). Survival amid unfair, inhumane, and unjust practices in America yielded resistance in various forms including abolition, emigration, armed resistance, Black Nationalism, Civil Rights movements, the Black Power movement, and proposals for reparations. Historical contributions to the field of psychology date back further than Wilhelm Wundt who is known as the father of experimental psychology, and the economic infrastructure of America dates back to the enslavement of Black people. Noting that Black Minds Matter is an acknowledgment that the psychological and physical trauma targeting Black people is worthy of our attention, study, and intervention; additionally, the well-being and contributions of Black people matter.

Historical and Contemporary Racial Trauma Despite literary, scholarly, and political attempts to deny or diminish its stain, slavery existed in the United States as one of the longest lasting brutal, inhumane systems in human history. The terror and trauma of the enslavement of Africans in America lasted

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hundreds of years and slave holders sustained the institution through state-sanctioned, legalized rape, abduction, torture, and murder. Adopting a liberation approach to traumatology requires educating one’s self on the history of racial trauma as well as its contemporary manifestations (Goodman 2015). Slavery in America started in the year 1619. A privateer, The White Lion brought 20 enslaved African people to Point Comfort or what is now Hampton, Virginia, who were seized from a Portuguese slave ship. Between the seventeenth and eighteenth centuries, numerous Africans were captured and kidnapped from various western countries on the continent of Africa. Once captured, they were held in small cells in Ghana, Senegal, and Nigeria, which all held a variation of the name of the “Point of no Return.” Out of the millions who were captured, between one and two million Africans died during their transport due to famine and disease. Traders of enslaved people even dishonored Africans who died during the treacherous Trans-Atlantic journey by throwing their bodies overboard. The deceased people whom they did not discard, were kept chained to living Africans, tormenting them physically, psychologically, and spiritually until their arrival to America. Those who survived included men, women, children, and families, who were torn from one another, sold to different slave owners. They were exploited for free labor in the production of crops such as tobacco and cotton. In 1777, Thomas Jefferson began drafting a plan for gradual emancipation of enslaved Africans, and America’s history was “birthed.” Since that day, the American Colonization Society in 1821 established a colony in Liberia. The Liberian colony was set up as a scheme to rid the United States of rebellious emancipated Black Americans who were organized abolitionists (The North American Review 1832). The prominent freed Blacks did not agree with this plan especially after President Abraham Lincoln called them to the White House, and stated, “Your race suffers greatly, many of them by living among us, while ours suffers from your presence” (Agent of Emigration 1862, p. 6). Anti-Black literacy was prominent during slavery. However, during the 1830s, laws were enacted prohibiting African education in Georgia and all public instruction of Africans in North Carolina (Mitchell 2008). The inhumane treatment consisted of rapes, torture, lynchings, and other forms of terrorism, continued until June 19, 1865. Known as Juneteenth, it was when the last enslaved Africans in Galveston County, Texas were informed they were freed. However, “slavery” continued but was disguised under new constructs. The abolition movement provoked the American Civil War, which “freed” approximately four million enslaved Africans; however, the unjustified hatred continued as Black Codes were introduced to control the movement and activities of those recently freed (DeGruy 2005). Black Codes were enacted to restrict formerly enslaved Africans and their descendants from progressing psychologically, economically, and politically. Emancipation in the United States fell far short of equity. Even when African Americans were progressing like the professionals in Tulsa, Oklahoma, their Black Wall Street was destroyed. The Greenwood community was perceived as a threat to White dominance due to the wealthiest of African Americans residing there (Messer et al. 2018). On June 1, 1921, numerous planes flew over the city and fires obliterated Greenwood (Messer et al. 2018). Jim Crow laws and Black Codes persisted from approximately 1865 to 1965.

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During the 1960s, the Civil Rights Movement emerged after 100 years from the emancipation. This era produced milestones of advancement for African Americans such as national leaders promoting freedom, justice, and equality. Yet, it was not devoid of oppressive tactics in need of eradication, which is exemplified by the genesis of the sit in movement that began on February 1, 1960. The sit in movement was designed around young Black people sitting in White establishments requiring service, and then staying seated even after being denied. The movement was a radical break from the status quo of civil rights at that time (Morris 1981). Systems to protect the culture of white supremacy are still pervasive as evident by racialized symbols of monuments and memorials honoring the Confederacy, which promoted slavery and perpetuated racism; these monuments were erected decades ago and many are still being protected today. The United Daughters of the Confederacy (UDC) were the driving force to preserve White supremacy (Heyes 2011). Mobs of White Americans brought their children to watch the lynchings, dog attacks, and firehoses used to suppress and terrorize Black people in America. To counter this, the Black Panther Party (BPP) was organized to provide “service to the people” although the government described it as “the greatest threat to the internal security of the nation” (Potori 2017, pp. 85–86). Due to the perceived threat and increasing power, the FBI and other government agencies harassed and prosecuted the BPP to near extinction (Potori 2017). Dr. Martin Luther King, Jr. was one of many prominent civil rights leaders to be assassinated. Toward the end of this era, mass incarceration erupted as a means of social control over Black communities. Research indicates, before 1980, the historical record was 137 per 100,000 as comparable to other nations but a series of court decisions and federal policies grew incarceration rates by 370% for Blacks and 334% for Whites between 1980 and 2000 (Justice 2014). Politicians declared a War on Drugs and states mandated lengthy sentences that erupted to an emergence of the Prison-Industrial Complex. However, the racial bias was clear. Research denotes the early 1990s was a period of targeting minorities based on drug of choice as evidenced by mandatory minimum sentences that was a 100 g to 1 g ratio for anyone possessing crack to cocaine, respectively (Tyler 2010). The rationale was that crack was more addictive than cocaine. The fact is that it is the same substance, but White users were more likely to use cocaine, which is the powder form that can be sniffed or freebased while Black users typically freebased crack (Tyler 2010). As a result, the New Era of Slavery or Modern Day Slavery emerged as mass incarceration of African Americans. Whether it is labeled as slavery or mass incarceration, Rothstein (2017) wrote, “We have created a caste system in this county, with African Americans kept exploited and geographically separate by racially explicit government policies” (p. XVII). These racial inequalities of America’s prisons were underscored in Ava DuVernay’s documentary, “13” where she exposed how minor behaviors of African Americans were over-criminalized. The school-toprison pipeline starts by labeling Black children as “deviant” and then they are hyper-criminalized in the juvenile justice system when the majority of them are arrested for nonviolent offenses (Rios 2006). African American children have experienced unlawful parental arrests and harassment, particularly paternal

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incarceration (Turney 2017). Parental incarceration has disadvantageous intergenerational effects on children, but paternal incarceration has deleterious consequences across the life course that increases inequalities (Turney 2017).

Historical and Contemporary Racial Trauma Definitions It is evident that Blacks in America have unarguably suffered from and through racebased trauma as well as the fear of discrimination. Race-based trauma is the psychological distress following exposure to a traumatic or stressful event based on one’s phenotype that is emotionally painful and uncontrollable; hence Blacks in America have experienced race-based trauma from 1619 to present day (Carter 2007). Another significant long-term effect is Post Traumatic Slave Syndrome (PTSS). This term was coined by DeGruy (2005) and is defined as a condition that exists when a population has experienced multigenerational trauma resulting from centuries of slavery and continues to experience oppression and institutionalized racism today. This suffering is labeled as intergenerational trauma, historical trauma, and transgenerational trauma, which is defined as trauma that is transferred between generations as a result of exposure to adverse experiences affecting offspring through physiological and psychosocial transmission (Brave Heart 2003). Black Codes, also known as Black laws, were an early example of systematic oppression, operationalized as the creation and enforcement of laws to govern the conduct of Black Americans to restrict their freedom after the Civil War and to pressure them to work for low wages (Cheney et al. 2006). Another example of systematic oppression is institutional racism as defined by Jones (2000) “as differential access to the goods, services, and opportunities of society by race” (p. 1212). These constructs illustrate how the systems, which were more overt prior to the Civil Rights movement, still exist but presently are more covert. To compound the effects of race-based trauma, historical trauma, and systematic oppression, African Americans also experience societal trauma, which is psychological distress following exposure to a traumatic or stressful event within one’s community. One’s community is operationalized as an immediate environment such as the neighborhood, school, social organization, or religious group; these events can include the overarching experience of oppression within these ecosystems. One effect of the multiple layers of trauma is the concept of “cultural paranoia.” Cultural paranoia is the constant vigilance to recognize potential threats given one’s phenotype (Carter 2007; Grier and Cobbs 1968). It is a healthy vigilance for survival and life preservation in a society with pervasive brutality and targeting of African Americans. In this way, being vigilant, or relying on “cultural paranoia,” may help potential targets to prepare for a racial affront. Nonetheless, vigilance may not help one to know when an event with considerable emotional or psychological power will occur. Another construct that affects African Americans is epigenetics. Epigenetics examines the molecular mechanism by which environmental factors such as diet, drugs, and stress triggers genetic expression (Yehuda and Lehrner 2018). For

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example, witnessing torture and heinous deaths, being separated from one’s family, and experiencing hundreds of years of violence, abuse, and trauma, are all stressors that change genetic expression. Understanding historical trauma means recognizing that descendants of slavery still live with the ramifications that were inflicted upon their ancestors. Trauma-informed mental health professionals will benefit from noting the diverse forms that racism takes in the lives of African Americans and therefore, must engage more effectively in research, clinical practice, and policy development. The Power and Control Wheel of Historical Trauma is a new tool to assist in this understanding.

Power and Control Wheel of Historical Trauma Outlined below are the categories from the Power and Control Wheel of Historical Trauma (PCWHT) (see Fig. 1), which illustrates the manifestation of contemporary racial trauma (Rogers 2020). The original power and control wheel was developed in Duluth, Minnesota for women who were survivors of intimate partner abuse, and it describes tactics used to achieve dominance over their partner. Similar to the original power and control wheel, the main category describes the different forms of power and control, and the subcategories are tactics used by perpetrators (Pence and Paymar 1993). The difference between the original power and control wheel and the PCWHT is that the original wheel focused on an intimate relationship whereas this wheel provides examples within microsystems and macrosystems. The eight categories and subcategories (i.e., tactics) can be applied to many oppressed ethnic groups, for example, African Americans, American Indians and Canadian First Nations, Armenians, Australian Aboriginals, Burundians, Cambodian Refugees, Caribbean and Caribbean Americans, Central and South Americans, Hmong Americans, Holocaust survivors, Japanese Americans, Korean Americans, Latino Americans, Middle Easterners, Northern Irelanders, Refugees, South Africans, Southeast Asians, War Veterans, and West Africans. Each subcategory is identified below but examples provided relate to the experiences of African Americans. The PCWHT demonstrates the multiple strategies employed to promote and protect racist ideologies and to maintain inequity through systematic denial of resources, violence, and psychological abuse. The recognition of these diverse tactics supports the argument for an interdisciplinary anti-racist response, including the discipline of trauma psychology.

Physical Violence The category of physical violence (see Fig. 2) consists of: genocide; political violence in war; institutionalized dehumanization through slavery and camps; institutionalized violence in prison and jail systems; and racialized police practices that result in coercion and threat through terror and torture. As aforementioned, the physical violence of enslavement and political violence against resisters, Black

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Fig. 1 Power and control wheel of historical trauma (Rogers 2020)

Panthers, and Dr. King, is presently seen in contemporary protestors who have shown up mysteriously killed due to a multitude of circumstances. The infliction of violence that befalls Black people who are incarcerated in the prison and jail systems transpires via psychological, physical, and sexual abuse. Research indicates during a six-month period that approximately 21% of men who are incarcerated are physically assaulted, and it is estimated between 2% and 5% are sexually assaulted (Wolff and Shi 2009). Wolff and Shi (2009) noted that 50% of assaults perpetrated by staff involved physical injury. Another study indicated “more than 80,000 prisoners each year are sexually victimized during incarceration, but only about 8% report victimization” (Kubiak et al. 2017, p. 361). One case representing these statistics is Kalief Browder who was a victim of each of the named abuses while housed at Rikers Island jail complex as an adolescent, and proper intervention was not provided. During his time at Rikers Island, he was in solitary confinement for 2 years as a result of him being a victim of prison violence. The unfortunate reality is that there are numerous unjust incarcerations of Black people in the United States, resulting from racial profiling, unfair court proceedings

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Fig. 2 Power and control wheel of historical trauma – physical violence

that routinely pressure innocent people to plea, bias among jurors and judges, overcharging by attorneys, and overwhelmed caseloads of public defenders. Correctional officers punching inmates in the face, trafficking in narcotics, inciting violence between gangs, instigating physical altercations, and requesting sexual favors, disproportionately affecting African American men. It is noteworthy that persons who are incarcerated are considered a vulnerable population; therefore, having sexual interactions is always deemed as nonconsensual (i.e., sexual assault) (Kubiak et al. 2017). In conjunction with the preceding factors, inmates presently also have to worry about contracting the 2019 novel coronavirus (COVID-19) due to confined quarters. Thus, a charge for petty theft can turn into a death sentence. Coercion and threat through terror and torture (e.g., the effects of policing) date back to slavery. The sole purpose of the police department during slave times was to hunt and find runaway enslaved Africans; therefore, one may question is this mentality unconsciously present in some forces and agencies today? Black boys are policed like no one else, not even Black men (Davis 2017). Being policed is just another aspect to add to the list of consequences they experience and these injustices by the police departments date back to slavery. Slave patrols and Night Watches, which later became modern police departments, were both designed to control the behaviors of ethnically diverse people (Kappeler 2014). Thus, it is not surprising the department that is supposed to “protect and serve” all, undoubtedly does not protect and serve all equally, especially African Americans. In some cases, police harassment simply meant people of African descent were more likely to be stopped and questioned by the police, while at the other extreme, they have suffered beatings and even murder, at the hands of White police (Kappeler 2014). The rate at which African Americans are killed by police is more than twice as

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high as the rate for White Americans. African Americans are not safe from the police. They have never been, but the question is will they ever be? Rayshard Brooks (2020), George Floyd (2020), Donnie Sanders (2020), Breonna Taylor (2020), Atatiana Jefferson (2019), Stephon Clark (2018), Botham Jean (2018), Philando Castille (2016), Alton Sterling (2016), Michelle Cusseaux (2015), Freddie Gray (2015), Tanisha Fonville (2015), Michael Brown (2014), Tanisha Anderson (2014), Eric Garner (2014), Akai Gurley (2014), Gabriella Nevarez (2014), Tamar Rice (2014), and Aura Rosser (2014) are just a few of the Black Americans murdered by police brutality in just the last 6 years.

Sexual Violence The historical trauma form of sexual violence is manifested through the tactics of sexual assault, systematic sexualization of certain groups of women and men, and racial sexual harassment (see Fig. 3). All three tactics produce decreased cognitive functioning such as an inability to concentrate, low self-esteem, disordered eating (i.e., over and under eating), and depression. It also creates a reductionist belief of people as sexual objects. Historically, White women have been depicted as embodying purity and virtue, while women of Color have been characterized by negative stereotypes such as the Jezebel or Mamie (i.e., an asexual mothering figure) (Accapadi 2007). Dispossession of the Africana female body, especially brutal rapes, is imprinted in American history. Moreover, the “legacy of slavery associates the sexual exploitation of African American women with distinct and dehumanizing and degrading

Fig. 3 Power and control wheel of historical trauma – sexual violence

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practices” and “to justify their enslavement and incessant sexual violation, the role of primitive sex object was ascribed” (Townsend et al. 2010, p. 274). Therefore, the Black body continues to be objectified and fetishized as demonstrated by the adultification and sexualization of Black girls. The American Psychological Association, Task Force on the Sexualization of Girls (2007), noted the trend in plastic surgery procedures to obtain Black physical features that were previously ridiculed, such as larger lips and hips. Research evinces that African American girls report higher rates of nonconsensual sexual encounters than Whites and Latinas, and many contend it is correlated with the constant reproduction of stereotyped and oversexualized African American women in the media (Townsend et al. 2010). Furthermore, in 2014, “searching on “Black girls” surfaced “Black Booty on the Beach” and “Sugary Black Pussy” to the first page of Google results, out of the trillions of web-indexed pages that Google Search crawls” (Noble 2018, p. 64). Objectification of a person, that is, not seeing the person as human, increases the likelihood of abuse and mistreatment. When the perpetrator’s beliefs are challenged, cognitive dissonance (i.e., the uncomfortable emotional experience due to the inconsistency) arises highlighting the inconsistency between their biases and antiprejudice views. This dissonance forces the individual to make conscious adjustments, either strengthening their biases or challenging them with presented factual information. This is exemplified as excuses are made and victim blaming ensues when Black women are perpetrated against, despite the presented factual information.

Systematic Resource Denial Systematic resource denial can be manifested through the denial of educational rights, environmental resources, land ownership via forced migration, and freedom and rights via mass incarceration (see Fig. 4). It also includes denial of collectivistic viewpoints via family disruption and separation due to recurrent residential moves, separations from parent figures, frequent change of caregiver, and frequent involvement with child welfare services and mentalicide (Durham and Webb 2014). Denial of educational rights is a tactic that has been used historically in the nullification of enslaved Africans’ right to literacy initially as a means of control. Presently, it is demonstrated in lack of equity in public school technology, enrichment programs funding, racism within curriculum and testing, and criminalization of parents who try to access quality education outside of their neighborhoods (BrunnBevel and Byrd 2015; Carpio 2018; Whaley 2018). Tax dollars affect school resources and the lack of resources increases the likelihood of youth criminalization, which manifests in the school to prison pipeline. A lack of resources produces a shortage of activities, thus increasing the likelihood that a child will engage in activities that will result in suspensions or expulsions. Suspensions and expulsions require the child to spend more time away from school; more time away from school

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Fig. 4 Power and control wheel of historical trauma – systematic resource denial

does not produce long term positive results (e.g., a youth interacting with the juvenile system at an earlier age). Research indicates African American students are three times more likely to get suspended than White students (Krezmien et al. 2006). Further research evinces that in conjunction with suspensions and expulsions, being taught by underprepared teachers, being referred for special education, and feeling a detachment from school are educational contributions to the overrepresentation of African American males in prison (Darensbourg et al. 2010). Also, researchers find that African American youth are alienated from the learning process, deterring them from academic achievement and funneling them into the criminal justice system (Darensbourg et al. 2010). Denial of environmental resources include corner stores instead of grocery stores, which is especially common in food deserts (i.e., areas where there is a lack of affordable or good quality fresh food) (Alviola et al. 2013). As a result of systematic racism, African Americans are disproportionately affected by denial of environmental resources due to intergenerational poverty and wage gaps despite educational attainment (Alviola et al. 2013; Yu et al. 2010). Even if a grocery store exists in proximity, the quality of food is typically subpar (e.g., nearly rotten fruits and vegetables). Limited transportation is another barrier common in food deserts, thus restricting food sources to within walking distance. This is significant because food affects

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one’s mood and cognitive abilities including focus, concentration, and emotion regulation. For example, a child whose diet is filled with sugar or processed food, will experience a lack of concentration and attentiveness in school. Ultimately, this can cause the child to be suspended for disruptive behaviors, which begins the cyclical process as explained in denial of educational rights. Denial of freedom and rights via mass incarceration is similar to the disproportionate school suspension and expulsion rate. African American males are more likely to be incarcerated than non-African American males as aforementioned. Inner city educational settings that are designed and structured to be more like prisons subconsciously permeate the impressionable minds of African American youth compared to suburban or rural schools. Community support is the outgrowth of collectivistic values, and when these values are disregarded and disrupted, Black people experience another form of historical trauma; the systematic destruction of Black families and communities has been observed from the capture and enslavement of African people to contemporary policies that economically penalize families with two parents living in the home. This aspect of racial trauma was enacted historically and contemporarily via family disruption and separation. Disproportionate recurrent residential moves, separations from parent figures, frequent change of caregiver, or involvement with child welfare services (CWS), anchor this point. These disparities are inordinately seen in Black families due to environmental and educational gaps in access to resources and opportunities. Family disruption is particularly seen in the family court system and in CWS cases. African American children are in the CWS system at alarming rates and that system continues to disservice these youth as they are: (a) more likely to be removed from the home, (b) less likely to be reintegrated back to the family, and (c) their parents are not as likely to receive culturally responsive parenting classes (U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau 2018). Research has indicated the overrepresentation of African American families in the CWS system has historically correlated with poverty and single parent homes. This factor creates an automatic bias for social workers to deem African American children more at-risk, leading them to be three times more likely than other children to enter the foster care system (Ayon and Lee 2005; Morton 1999). Continual family separation leads to consequential problems for youth such as: (a) increased health problems, (b) risk taking behaviors, (c) trauma exposure, and (d) intergenerational recidivism (Amrami and Javier 2020). Decolonial psychology is not simply a metaphor but also explains the need to eradicate material and economic inequities including access to land for the restoration and health of Black mental well-being. Denial of land ownership via forced migration has had adverse compounding effects on African Americans. The road to wealth is real estate and land ownership, and it is still the great divide in socioeconomic status because one cannot build generational wealth when one does not own property. Research indicates that the number of African American farmers has been declining at a faster rate than their White counterparts (Balvanz, et al. 2011). Historically, White

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landowners sought the expertise of African American farmers. However, in the last 100 years, land ownership of African Americans has drastically decreased from 926,000 farmers to approximately 40,000 farmers (Balvanz et al. 2011). Research indicates the initial decline was a result of increased farm machinery and the end of sharecropping. Current factors that have led to the substanital decline of Black farmers are: (a) structural changes of policies favoring large farms, (b) cumbersome tax laws, (c) mortgage foreclosures, (d) intestate death of landowners resulting in partition sales, and (e) outright discrimination (Balvanz et al. 2011). Playing a role are also the U.S. Department of Agriculture’s discriminatory lending practices, which include: (a) not providing African American farmers access to credit, (b) granting less credit to African American farmers than White farmers, and (c) distributing loans to African American farmers too late in the farming season for maximized farming production (Balvanz et al. 2011). Furthermore, the Agricultural Stabilization and Conservation Service (ASCS) was designed to provide technical assistance to farmers, but in some counties they created the ability for White farmers to buy the Black-owned farms when they were put up for auction (Hinson 2018). The preceding discriminatory practices are examples of federal systematic oppression, which still adversely affect Black farmers. These same biased and inequitable practices are seen with mortgage lending as research indicates approximately 34% of African American applicants are rejected whereas only 14% of White applicants are rejected (Ambrose et al. 1995), and neighborhood appraisals worsened this system. Research indicates that African Americans were barred from the opportunity of home ownership and were restricted to inadequate and finite inhabitable space (Woods 2012). The end result of all of the subcategories is Mentalicide, which is Mental Homicide or Mental Suicide. Mentalicide as a homicide “will develop when an individual has been estranged from thinking clearly, coherently and independently due to extreme psychological, physical and emotional violence” (Reid et al. 2005, p. 67). Furthermore, these conditions produce an isolation to knowledge and information that results in a destruction to African Americans self-development, and ultimately Mentalicide is used in order to make oneself seem as insignificant as possible to those who maintain and perpetuate the veil (Reid et al. 2005). When the authors introduced the term veil, they were referring to the veil that was created by slavery and transferred from generation to generation through institutions of mass media (Reid et al. 2005). Institutions have controlled the narrative and the image of the Black race via stereotypes for more than 400 years. This has led to Mentalicide, helplessness, hopelessness, and demoralization through the denial of needs, thus producing a sense of foreshortened future, “a negative evaluation of what the future offers rather than an altered sense of the future itself” (Ratcliffe et al. 2014, p. 1).

Economic Abuse The historical trauma of economic abuse (see Fig. 5) can be seen in the tactics of feeling that: (a) one cannot advocate for oneself in an employment setting because of

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Fig. 5 Power and control wheel of historical trauma – economic abuse

direct or indirect retaliation and implication of noncompliance from the oppressive systems of one’s employment site; and (b) limiting access to economic advancement and financial stability. Wage discrimination and differentials have been ongoing issues in labor economics (Biddle and Hamermesh 2013). Research has evinced that the wage gap is not a skill difference but rather racial discrimination (Coleman 2003). While some fields are actively attempting to have more diversity in their senior positions, once in the position, discrimination still ensues (Moyes et al. 2000). The statistical discrimination model continues to provide evidence for the wage gap and how the wage gap specifically affects Black women’s pay (Fadlon 2015; Hughes and Dodge 1997). The first tactic produces fear of unemployment when there is an inability to advocate for one’s self. Job and career insecurity have the African American person staying in an oppressive environment due to fear of being rejected, excluded and ostracized in their industry (Dillard 2016). When a person is job insecure, mentalicide is produced and anxiety is created around the constant fear of being harassed and subjected to subservient treatment. Work-related stress is a serious occupational hazard and African American women have additive stressors because of more restricted economic opportunities (Norman and Tang 2016). Economic abuse occurs not only in unemployment rates among Black Americans in limited resource environments, but also exists in corporate America as African American women continue to experience a pay gap and are more likely to be classified as poor (Norman and Tang 2016). This form of treatment, known as “gendered racism” (i.e., oppression due to race and gender) (Lewis et al.

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2017), is often seen in workplaces where White women benefit from White privilege when working with Women of Color, especially when they weaponize their tears (Accapadi 2007). White women have a dual identity as the oppressor and the oppressed, and an inner tension is developed in circumstances with Women of Color (Accapadi 2007). This inner tension can result in what has been called “White fragility,” which can show itself in racial conversations. White fragility is “the state in which even a minimum amount of racial stress becomes intolerable, triggering a range of defensive moves” (DiAngelo 2016, p. 247). Some of these behavioral moves include argumentation, silence, crying, and leaving the stressinducing situation (DiAngelo 2016). When a situation arises in the workplace and a White woman cries about it, societal norms suggest she is helpless and others present sympathize with her (Accapadi 2007; see also DiAngelo 2016). In these circumstances, the White woman is acknowledged while making the validity of the Woman of Color’s feelings invisible and pathologized. DiAngelo (2016) states, White people hold American capital and strategies to maintain their position over people of color. These are some reasons why Black women feel they have to mask their feelings, which White people stereotype as the Angry Black Woman. However, gendered racism occurs so frequently that if a Black woman thought about the magnitude of their discrimination, they would cry all the time (Burton et al. 2020). The second tactic is limiting access to economic advancement and financial stability. There are various mechanisms for this access denial, including but not limited to predatory businesses primarily found in Black communities with limited resources (i.e., payday loan centers, title-pawn establishments, and cash checking locations). These businesses are typically located in food deserts and are easily accessible without transportation. However, they have exuberant interest rates that leave people in impoverished and low socioeconomic communities being placed in a never-ending cycle of using those systems (Carvalho et al. 2016). Researchers debate whether repeatedly borrowing at high interest rates is an adaptation to their economic environment, a “culture of poverty” shapes their preferences leading to mistakes, or is it scarcity, “having less than you feel you need,” which may lead to decision-making errors and myopic behavior (Carvalho et al. 2016). It is not the perception of having less than one needs (i.e., the culture of poverty), instead it is the reality of poverty (i.e., scarcity) that shapes these decisions. Inequitable lending practices and higher mortgage annual percentage rates juxtaposed to Whites disadvantages African Americans considerably (Kashian et al. 2014). These practices also contribute to economic abuse as a form of historical trauma.

Appropriation of Cultural Resources, Traditions, and Knowledge Research indicates cultural appropriation can be morally problematic as it often embodies misrepresentations and misuse of material from historically dominated socially marginalized groups (Matthes 2016) (see Fig. 6). This category includes

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Fig. 6 Power and control wheel of historical trauma – appropriation of cultural resources, traditions, and knowledge

taking credit for a targeted group’s ideas and traditions as well as manipulation of information and providing disinformation. Other tactics which are indirectly tied to cultural appropriation include: (a) treating someone as “less than” because of level of education; (b) minimizing someone’s status or title; (c) forcing members of the targeted group to change their interpersonal style and communication to fit others; (d) forcing member of the targeted group to qualify or prove themselves; and (e) intellectual abuse and assertion of one’s privilege over targeted group. These subcategories obliquely relate because in many of these instances there is still procurement of African American knowledge and resources in the midst of belittlement from the dominant culture. This category reveals how White norms became universal norms, which leads to oppression and contemporary racism. Manipulation of information (i.e., misinformation) and providing disinformation, which is the deliberate and purposeful assertion or dissemination of false or misleading information, occurs in every context from academia to policy (Fetzer 2004). This includes anti-Black curriculum and books, which deny the contributions and perpetuate stereotypes of Black people. Scholarship that erases the contributions of Black scholars is also a form of manipulation of information that can be seen in trauma scholarship and trauma training programs. Misinformation and disinformation continuously put African Americans at a disadvantage for various opportunities as exemplified by the narrow circles (predominately White) in which professional opportunities are shared, advertised, and encouraged. Misinformation and disinformation are also passed generationally and educationally (e.g., there are some schools that have textbooks which indicate that slavery was an option). These textbooks originated as part of the UDC efforts which geared “rhetorical reconstitution, a

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process that serves to rebuild the fractured requirements of a de-collectivized people” toward children in the form of catechisms (Heyes 2011, p. 56). This is also seen in the form of taking Black people’s ideas and using it as their own as it has been seen throughout history, particularly with inventions. Also, during movements like the Me Too, which was started by Tarana Burke, but for a long time credited to Alyssa Milano, until the narrative was corrected (Garcia 2017). Intellectual abuse is operationalized in this chapter as the degradation or disrespect for the thinking or learning of a person from a marginalized identity group. Intellectual abuse and assertion of one’s privilege over the targeted group is demonstrated in the unequal treatment of employees. African Americans are treated as “less than” on their job despite their equivalent level of education due to racism, as noted in rates of promotion and lack of diversity in high level positions (Hughes and Dodge 1997; Lloyd-Jones 2009). Black people in diverse work settings have reported higher rates of workplace discrimination including being overlooked for promotion while being expected to train people (i.e., their manager or boss) who are less qualified. African Americans who have the strategy and skill set to be a part of the C-Suite or at the director level are constantly overlooked for a promotion, and the title is given to their White counterpart. African Americans are expected to complete a job of more than one person, and when the individual presents a reorganization plan, the management makes excuses about why they cannot hire someone else or critique the individual’s performance (Hughes and Dodge 1997). Additionally, when the individual resigns or is terminated, the individual’s duties are assigned among several people, the company hires someone, or the company implements the individual’s proposed plan. This treatment is also seen when members of society minimize a Black person’s status or title by staying, “Ms.” or “Mr.” instead of “Dr.” It is further manifested when an African American person holds the credentials but they are put in circumstances where they have to constantly qualify or prove themselves (Lloyd-Jones 2009). Lastly, in the work setting African Americans’ interpersonal and communication style are often regarded as deficient because it is different. Emotional intelligence is decontextualized to consider the ways in which Black people express their feelings and the ways in which Whites respond to this emotional expression. Research indicates that Blacks are more accurate at recognizing emotions in ethnically diverse group settings and are better able to recognize emotion regardless of race compared to Whites (Whitman et al. 2014). African Americans, specifically women, are made to feel guilty because they: (a) speak in an assertive or confident tone that is more likely to be interpreted as an aggressive tone, (b) do not cry in the office, or (c) show overt sympathy. All of these actions do not align “with the “standard of humanity” which is rooted in “White norms” (Accapadi 2007).

Spiritual Abuse The category of spiritual abuse consists of two tactics: distortion and denial of religious and spiritual views, and use of religion to disempower groups of people

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Fig. 7 Power and control wheel of historical trauma – spiritual abuse

(see Fig. 7). Although spiritual abuse predates slavery, faith and religion were used to justify slavery (Cone 1985; Lincoln 1973). Indigenous practices were prohibited and teachings from the Bible were primary (Cone 1985). However, the teachings were false. It was preached that Jesus was White and excerpts such as “Slaves obey your master” were used to silence the slaves (Cone 1985; Oliver 2014). Presently, some African Americans still experience oppression when they cannot acknowledge their ancestral beliefs freely or if religion is used to promote spiritual-bypassing which requires not addressing or acknowledging injustice and instead focusing on heaven or gratitude.

Race Socialization Via Cultural Abuse First, before discussing this subcategory, it is necessary to define race socialization (see Fig. 8). Race socialization is the specific verbal and nonverbal messages transmitted to younger generations for: (a) the development of values, attitudes, behaviors, and beliefs regarding the meaning and significance of race and racial stratification, (b) intergroup and intragroup interactions, and (c) personal and group identity (Lesane-Brown 2006). It is common for people being held against their will to take on the views and attitudes of their captors (Adeniyi 2018). For example, as a means of survival, enslaved Africans adopted the attitudes and behaviors of their torturers. This includes behaviors such as taking on the role of the slave monitor, and physically abusing other enslaved Africans. In contemporary times, this can be seen as

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Fig. 8 Power and control wheel of historical trauma – race socialization via cultural abuse

“internalized racism (i.e., endorsement of negative stereotypes of one’s racial group)” (James 2017, p. 659) and imposter syndrome (i.e., “feelings of intellectual incompetence among high achieving individuals”) (Bernard and Neblett 2018, p. 279). One of the most insidious and pervasive symptoms of race-based trauma is the adoption of the slave master’s value system. This promotes a racialized capitalistic view that Black people’s worth is based on their labor as opposed to their humanity, which is termed Post Traumatic Slave Syndrome (PTSS) (DeGruy 2005). Through centuries of slavery and the decades of institutionalized oppression that followed, many African Americans have been socialized to be something akin to White racists (DeGruy 2005). Due to the decades of oppression and brainwashing that took place during slavery, some African Americans have adopted negative perceptions of their community members. While overall Black people score high on self-esteem, some hold high individual self-esteem but negative collective esteem (James 2017). From the time that enslaved Africans were captured and transported to the United States, they were seen as an inferior sub-group. They saw their captors as being wealthy and powerful, whereas they were captives and financially disenfranchised. This category is multifaceted. It includes: (a) colorism; (b) not allowing one to observe or participate in their cultural practices; (c) forcing one to adopt a culture to be accepted into the larger society or structure; (d) confiscation of land; (e) banning of language; (f) denial of biopsychosocial consequences of oppression; and (g) pathology of activist and activism. Colorism is defined as favoring a person and showing preferential treatment based on skin tone such that the closer one is to the skin tone of White people the

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better one is treated (Townsend et al. 2010). This difference in treatment has been a global manifestation of racism and was seen in the treatment of slave owners and colonists who systematically treated persons of lighter complexion better psychologically and financially in Africa, Asia, and Latin America. This difference in treatment resulted in internalized oppression such that with Black, Asian, and Latino families’ lighter complexion children have been more highly regarded than their darker complexion peers. This concept extends to slavery times when the lighter skin slaves worked in the plantation owner’s house versus the field. More often than not, this occurred because the plantation owner systematically raped and impregnated enslaved women, and their children who were then granted access to the house to ensure easier access of the owner. Underlying these experiences is the myth of White supremacy which has been promoted to White people and people of color and has been supported and enforced by abusive, racist practices and policies historically and currently. Therefore, the closer a person’s skin is to White, the more superior they have been treated in the workplace, media, and interpersonal relationships. Colorism has even been shown in criminal justice research in studies that find that potential jurors endorse the idea that the more African a person’s features appear, the more they are perceived as dangerous or criminal and receive harsher criminal justice outcomes (Viglione et al. 2011). The subcategory of denial of biopsychosocial consequences of oppression is typically detected in research and academia. For example, denying the concept of epigenetics or only applying it to certain groups of people such as descendants of the Holocaust but not of enslaved Black people in America is another form of racial trauma. Furthermore, this is more apparent when mental health professionals and other members of society dismiss the notion of PTSS among survivors of racial traumatization. Black psychology notes that survivors of racial trauma may go beyond coping to resistance through activism as an important part of their empowerment and healing (Bryant-Davis and Ocampo 2006). Activists and activism are often pathologized and misunderstood, with observers focusing on protestors’ anger, instead of the injustices they are angry about. This pathologizing, however, is also adjusted by race. In 2020, White protestors who carried guns and protested for their right to go unmasked during a global pandemic were not criminalized by the police, but Black protestors who marched without guns about the unjust killings of their community members were often met by the police with violence and arrests (Biggs 2020; Muse 2020). Activism is the policy or action of using vigorous campaigning to bring about political or social change (Dumitrascu 2014). It involves awareness (i.e., dissemination of information), advocacy (i.e., organizing a movement and carrying out an action), and action/reaction which is the more proactive and aggressive form (e.g., protesting). Common ways to participate in activism are campaigning that include protests, strikes, or demonstrations that are demand-driven and take form in the short term, and joining organizations that speak out against a topic. Organizations that speak out against a topic are usually more structured than the preceding and are long term in nature.

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In a study by Bryant-Davis (2005), activism is defined as a pathway or tool for individual and collective empowerment and agency that facilitates the progression out of self-doubt and insecurity for survivors of interpersonal trauma. The study revealed that 26% of participants engaged in such activism as a method for coping with their trauma (Bryant-Davis 2005). Activists typically experience both benefits (e.g., truth and justice; understanding the roots of violence; empathy and sympathy; empowerment, agency and internal locus of control) and challenges (e.g., reexperiencing the trauma; unprocessed trauma, i.e., “It was my fault”; and limited effect on the structures of silence) of engaging in activism (Staub and Vollhardt 2008). Presently, all forms of activism are in progress as the recent unjustified killings of African Americans, which means the need for mental health is rising.

Psychological Abuse Emotional abuse can be expressed in two ways, manipulations and verbal abuse (e.g., name calling) and psychological abuse, gaslighting, humiliation, and guilt through deception (Loue 2005) (see Fig. 9). This category consists of: (a) shaming; (b) “just get over it” or “it’s not as bad as it seems”; (c) blaming, minimizing, and denying; (d) create vacant esteem; (e) use of microaggressions and minimizing their use or dismissing objections when used (Johnson and Johnson 2019); (f) condemning the body and its beauty; and (g) lack of ownership of the role the holder of privilege plays.

Fig. 9 Power and control wheel of historical trauma – psychological abuse

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Shaming, blaming, minimizing, and denying are present when perpetrators and beneficiaries do not acknowledge the reality of racism. For example, when a racial remark is made in a “humorous” or “sarcastic” manner and the holder of privilege tells the African American person that he or she is being sensitive but they are engaging in a psychological abuse tactic (Perez 2017). African Americans should not be shamed, told to just get over it, or be informed that it was not as bad as it seemed, when it was insensitive, racist, and disrespectful. Denial of racism is harmful when done by any community member and especially by mental health professionals. Insufficient development of self-esteem (i.e., vacant esteem is the state of believing oneself to have little or no worth) (DeGruy 2005). The development of insufficient self-esteem or vacant esteem is traced back to slavery, when enslaved Africans were not considered people because of their race. They were demeaned and treated as less than simply because of their skin color. King (1981), author of “The Biology of Race,” sums up the theory of race as a concept of society that insists there is a genetic significance behind human variations in skin color that transcends outward appearance. However, race has no significant merit outside of sociological classifications. There are no significant genetic variations within the human species to justify the division of “races” (King 1981). Yet, there is division, thus, how could African Americans develop self-esteem when they were constantly in the position to believe that they would never be equal to the slave master? As aforementioned, systematic oppression is the modern day Black Code and how are African Americans expected to achieve when they were not allowed to play the game until hundreds of years later? Despite these pervasive oppressive systems, some do report positive self-esteem as a result of positive racial socialization by Black parents and institutions (Anderson et al. 2019; Evans et al. 2012). Microaggressions are subtle, verbal and nonverbal slights, indignities, and denigrating messages directed toward an individual due to their group membership that are often automatic and unconscious, and may take the form of microinvalidations, microinsults, and microinequities (Johnson and Johnson 2019). A bias is an evaluation or belief both favorable and unfavorable, and implicit biases are unconscious beliefs, attitudes and stereotypes that affect our understanding, actions or decisions. Examples of implicit bias are microinvalidations, which are communications that subtly exclude, negate or nullify the thoughts, feelings or experiential reality of a person’s identity (Johnson and Johnson 2019). For example, saying “You’re handsome/intelligent for a Black guy” or “I didn’t know you were Black, you don’t look like it” are microinvalidations. Microinvalidations also include statements that assert race played a minor role in life success. Microinsults are unconscious verbal, nonverbal, and environmental communications that subtly convey rudeness and insensitivity that demean a person’s heritage or identity (Johnson and Johnson 2019). For example, “You’re pretty for a dark skin girl,” or “How did you get into that school?” Microinsults can pathologize cultural values and communication style as well as include assumptions about criminal status. Microinequities “describe the pattern of being overlooked, under respected, and devalued because of one’s race or gender” (Johnson and Johnson 2019, p. 21).

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“Microinequities are delivered as subtle snubs or dismissive looks, gestures, and tones, and these exchanges are so pervasive and automatic in daily interactions that they are often dismissed and glossed over as being innocent and innocuous” (Johnson and Johnson 2019, p. 21). Condemning the body and its beauty includes minimization of one’s beauty as well as making fun of facial features and other body parts. However, this is not a new phenomenon. The ostracization of Black bodies has been around for centuries. In the nineteenth century, Sartje Baartman and Julia Pastrana had uncharacteristic physical features (e.g., ideal masculine body, differently shaped buttocks, a beard, and mustache) labeling them as grotesque individuals, and assigning them names such as The Hottentot Venus and The Ugliest Woman in the World, respectively (Bryce 2001; Ray 2009). Ms. Baartman was misled into becoming exploited by a European man who later became her “trainer” because she had an abnormally huge buttock and labia (Bryce 2001; Ray 2009). Unfortunately, two centuries later, Caster Semenya was subjected to similar treatment due to uncharacteristic physical features (Ray 2009). On August 19, 2009, Caster Semenya won a gold medal and she was ordered to undergo gender verification (Cooky and Dworkin 2013). Ray (2009) wrote, “Two centuries separate Baartman and Semenya, yet they are inextricably linked by the same fraught history that surrounds the West’s fascination with and disregard for the Black body” (p. 19). Interestingly, what was exploited then is “worshipped” presently, as we see White women having surgical procedures for larger lips, breasts, and buttocks.

Long-Term Effects of Historical and Contemporary Racial Trauma One effect of historical trauma is Racial Battle Fatigue which is the psychological stress experienced by racially marginalized members of society who have to navigate the trauma of institutional and individual racism (Smith 2008). As previously mentioned, epigenetics is a cause that makes African Americans more susceptible to anxiety, stress, and trauma. Other negative effects are: (a) aggression, (b) denial, (c) guilt, (d) rage, (e) shame, (f) low self-esteem, (g) impact of work or school performance, (h) acute stress disorder, (i) anxiety, (j) depression, (k) eating disorders, (l) posttraumatic stress disorder, (m) substance use disorders, and (n) physical health complaints (Comas-Diaz et al. 2019; Nuru-Jeter et al. 2009). Spiritually, a person may feel distant from spiritual and religious practices. Furthermore, Cornel West coined a term, “Black nihilism” which is the “internalized sense of worthlessness and inferiority that exists so deeply in the Black community” (Guerrier 2019, p. 102). As aforementioned, another significant long-term effect is PTSS. To understand PTSS, it is important to understand the connection this term has to post-traumatic stress disorder (PTSD). The terms diverge because PTSS is a multigenerational syndrome that has affected African Americans since slavery began, whereas PTSD occurs when a person has personally experienced a traumatic event. However, the criteria of PTSD directly align with PTSS and the cyclical impact it has from one generation to the next. Furthermore, complex posttraumatic stress better conceptualizes the African American experience. Complex posttraumatic stress has been conceptualized to occur when one is

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exposed to sustained, recurring, and, or multiple traumas, particularly during childhood, which can lead to common posttraumatic stress symptoms as well as anxious arousal and aggressive behaviors (Cloitre et al. 2009). DeGruy (2005) highlights the aspects of multigenerational trauma paired together with oppression and the lack of opportunity to access the benefits available in society. There are many characteristics rooted in slavery that African Americans possess today and are unaware of the impact. For example, a White mother gets a compliment about her son in school from a Black mother. The White mother thanks her and offered a compliment to the Black mother about her son and before she could finish the compliment, the Black mother goes on to say how her son is such a mess. Although she is proud of him, she uses a defense mechanism that was used by mothers who were enslaved Africans. DeGruy attributes this behavior to enslaved African mothers trying to keep their children (especially their daughters) from being sold or raped by the slave masters, so they would make their children seem to be less desirable. The enslaved African mother’s denigrating statements about her daughter were spoken in an effort to dissuade the slave master from molesting or selling her, and of course, no one would fault her (DeGruy 2005). Slavery required enslaved parents to teach their children how to survive in the midst of dangerous conditions (Wilkins et al. 2013). Another concept DeGruy (2005) discussed was displaced anger resulting in violence. Children exposed to violence undergo lasting physical, mental, and emotional harm. Children who witness violence have an increased likelihood to commit acts of violence as adults. Slavery was the ultimate act of violence towards the people taken from Africa. African Americans have a reason to be angry. Anger and violence were modeled in every aspect of enslavement. Individuals were forcibly captured, chained, and regularly beaten into submission over hundreds of years (DeGruy 2005). It is no secret that the violent and angry tendencies exhibited today have been passed down from generation to generation of African American families because of the effects of slavery. Consequently, this violence and anger continued past the abolishment of slavery. Combining the passing down of anger and violence from slavery, and children exposed to violence in the household and community, is one way to understand how African Americans exhibit displaced anger resulting in violence. Bryant-Davis (2019) notes the problematic ways in which racism is systematically ignored in the trauma field. There is even a contemporary trend of calling the widespread racial terror of hundreds of years a “little t trauma,” while the trauma against one individual on 1 day is deemed “a big T trauma.” “Little t trauma” is the term used for events that are distressing but do not fall into the life-threatening category of “big T traumas.” Examples of “little t traumas” are emotional abuse, death of a pet, or loss of a significant relationship such as a divorce. Placing the oppression and dehumanization of entire groups of people in the category of distressing but not major, is minimizing the impact and oppression on the life and life integrity of individuals. Denial of the psychological impact of racial trauma is not only a theoretical oversight and erasure, it creates clinical harm by minimizing the experience of an entire group of trauma survivors.

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Clinical Applications when Working with Black Americans Oftentimes when working with clients whether clinically or forensically, mental health professionals neglect to explore sociocultural factors during the intake process or case conceptualization. When mental health professionals who are not traumainformed do not take into consideration sociocultural factors, they often misattribute or mislabel their client’s presentation. Furthermore, they may overlook the adverse impact of the long-term effects of slavery on presently oppressed African Americans. As DeGruy stated, “You Cannot Heal What You Don’t Understand.” Thus, it is critical for mental health professionals to comprehend that life is more than just “unfair” and that out of historical trauma developed the deleterious effects of contemporary oppression in the forms of systematic oppression and the manifestation of posttraumatic stress symptomology. As Bryant-Davis and Ocampo (2005) wrote, “Perhaps this is why ethnic minorities are often accused of oversensitivity to racism, because when they respond, they are responding not only to the incident but to the pervasive, covert, ambiguous, and unnamed institutional and cultural events against which the overt incidents are framed” (p. 575). Therefore, it is critical as a trauma-informed mental health professional to acknowledge the impact of historical trauma because it influences one’s ideologies as well as identity and interpersonal and intrapersonal relationships. Before discussing intervention approaches, it is necessary for practitioners to gather pertinent information outside of one’s history via interview and assessment. One interview technique is the ADDRESSING model by Hays (2016). This model captures a person’s Age and generational influence, Developmental or other Disability, Religion or spiritual orientation, Ethnic and racial identity, Socioeconomic status, Sexual orientation, Indigenous heritage, National origin, and Gender identity (Hays 2016). Obtaining these intersectional factors from the client’s point of view provides insight into the client’s identity and worldview. This model is culturally informed as well as trauma based. Assessments include Race-Based Traumatic Stress and Symptom Scale (Carter et al. 2013), which is a group-level assessment and reactions to described racist experience; Race-Based Traumatic Stress Interview, which helps the practitioner obtain demographics and racial discriminatory experience(s); and Race-Based Traumatic Stress Interview Protocol and Test Battery, which gives the interviewer a deeper exploration of individual experiences and emotional reactions developed from several valid and reliable clinical measures. Culturally syntonic interventions include: liberation psychology; transpersonal psychology; Ubuntu psychotherapy, womanist psychology, and Soulfulness (Bryant-Davis and Comas Dias 2016; Harrell 2018; Van Dyk and Nefale 2005). One group intervention includes the Emotional Emancipation Circles conducted by the Association of Black Psychologists, which creates space for narratives that affirm the humanity of Black people in groups that are facilitated by and attended by Black people (Barlow 2018; Grills et al. 2016). Liberation psychology is to free all people from the enslavement of distorted aspects of their inner lives and from the binding yoke of injustices experienced in their lives within community. When one is able to experience restoration in community, one can heal (Duran et al. 2008).

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Transpersonal psychology, “. . .offers the vision of a truly inclusive psychology that spans the many forms of human diversity—a psychology that opposes specious justifications for the oppression of any person or group [because] it challenges the egoic view that truth is possessed by the society most effective at disposing of its rivals” (Hartelius et al. 2007, p. 153). Moreover, it is important to remember that the ways clients voice their concerns and the ways in which clinicians interpret their narratives shape conceptualization and treatment. Psychologists need to add racial traumatization to the diagnostic manual either within post-traumatic stress or as a stand-alone diagnosis. As Carter (2007) notes, the experiences of racial trauma that clients may share include subtle invalidations and overt forms of racial harassment and discrimination. A practical tip that is not a full intervention involves microinterventions to address microaggressions because they empower targets and bystanders to respond (Comas-Diaz et al. 2019). For example, asking the perpetrator who they were referring to when they made the statement and then correcting them at the time of the incident. Microinterventions are used to defuse the situation by disarming the microaggressions and educating the perpetrator. Seven practical steps that clinicians can take to address anti-Blackness racial traumatization are: 1. Educate themselves continuously on Black history and contemporary racism. 2. Actively interrogate themselves about any implicit bias they hold about Black people. Then work to counter these biases as they will harm the therapeutic process and they are harmful to the individual who holds these beliefs. 3. Do not wait for the client to introduce the topics of race and racism. While the specific language may vary, communicate not only an openness to discussing experiences of racism but also a clear statement about an awareness of the potential mental health consequences of racism and a commitment to anti-racism. 4. During the intake, routinely ask questions about experiences of racism, discrimination, or bias. Do not respond to disclosures of racial stress or trauma with silence, victim blaming, or minimizing. Respond with the level of support that all trauma survivors deserve. 5. During the intake, ask questions about their intersectional identities, multiple identities of marginalization or oppression. Do not overlook client’s particular experiences, for example, being a Black American with Nigerian born parents or being a Black trans woman. 6. As you consider the diagnosis and treatment plan, actively and openly discuss your thoughts and observations with your client to counter the power dynamic and to engage the client in the therapeutic process. 7. For treatment, consider using the model Bryant-Davis and Ocampo (2006) outline for additional model of addressing racial trauma which includes: (a) acknowledgment, (b) sharing of the narrative(s), (c) mourning the losses, (d) anger, (e) rebuilding trust, (f) countering shame, (g) self-blame and internalized oppression, (h) developing healthy coping strategies, and (i) resistance strategies.

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1. Empower clients to acknowledge experiences of racism and provide the emotional regulation skills for them to share their narratives. 2. Encourage clients to give themselves permission to mourn the losses of racism and validate the diverse feelings that emerge including anger and frustration. 3. Facilitate the process of clients rebuilding trust that may have been broken by experiences of racism so they are not isolated. 4. Then actively work to address internalized racism, or the ways they have come to believe negative stereotypes about themselves or their community. 5. Provide psychoeducation on healthy coping strategies such as social support and spirituality, as well as resistance strategies such as activism and strategic anti-racism in their workplace and personal relationships. 6. Be mindful that being an anti-racist therapist requires additional cognitive and emotional labor so engage in self-care, community care, and continued learning for the journey ahead.

Key Points • The mental health of Black Americans is affected by historical and contemporary racial trauma. • Erasure of Black psychologists’ contributions to civilization and the field of psychology are forms of racism. Black psychology dates back to the Nile Valley civilization of Ancient Egypt. • Slavery, Civil War, Jim Crow, Civil Rights, and Mass Incarceration are manifestations of racism. • The Power and Control Wheel of Historical Trauma (PCWHT) provides contemporary examples of the ongoing realities of historical trauma, which has also been referred to as intergenerational trauma and ancestral wounds. The PCWHT has eight categories: (a) physical violence; (b) sexual violence; (c) systematic resource denial; (d) economic abuse; (e) appropriation of cultural resources, traditions, knowledge; (f) spiritual abuse; (g) race socialization via cultural abuse; and (h) psychological abuse. In each of these categories, tactics used by the perpetrator are listed so practitioners can have a better understanding of the ongoing realities of oppression. • Long-term effects of historical and contemporary racial trauma include Post Traumatic Slave Syndrome which has deleterious effects of the mind, body and spirit. • Trauma-informed, healing-informed, social justice-oriented mental health practitioners who are anti-racist and decolonial in their commitment to developing restorative practices that affirm the value of Black people’s lives and minds will be a vital part of the road to racial equity.

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Summary and Conclusion Anti-Black racism in the United States has endured for hundreds of years and has caused physical and psychologically deleterious effects on African Americans. Racism is a historical and contemporary trauma that overwhelms the psychological resources needed to cope with everyday stressors by inflicting physical, economic, sexual, and emotional harm. Racism threatens the life integrity and well-being of Black people in America with tactics ranging from State sanctioned police brutality to mass incarceration. Trauma-informed clinicians of all races must be not only culturally aware, but actively anti-racist in their therapeutic stance, facilitating not only coping and healing but also resistance. Dehumanization, criminalization, and systematic pathologizing of Black people are tools that uphold racist ideologies. As Herman (2015) noted, it is easy to side with perpetrators. All they require is our silence. When trauma-informed mental health professionals leave racism out of their assessment, treatment planning, and interventions they support the continued violation of Black people. Slavery, Civil War, Jim Crow, Civil Rights, Mass Incarceration, color blind approaches to mental health, and racism denying trauma therapy are all manifestations of racism. There are, however, trauma-informed, healing-informed, social justice-oriented therapists who are anti-racist and decolonial in their commitment to developing restorative practices that affirm the value of Black people’s lives and minds.

Cross-References ▶ Interpersonal Violence and Forced Displacement ▶ Intersectionality ▶ Microaggressions and Implicit Biases: Rooted in Structural Racism and Systemic Oppression ▶ The Experience of Children and Families Involved with the Child Welfare System ▶ Youths’ Exposure to Violence in the Family

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Defining Gun Violence Using a Biopsychosocial Framework: A Public Health Approach Sara Kohlbeck, Lauren Pederson, and Stephen Hargarten

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gun Violence as a Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gun Violence as a Complex Biopsychosocial Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Biological Component of Gun Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychological Component of Gun Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Component of Gun Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gun Violence Prevention and Haddon’s Matrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Examples of Gun Violence Prevention Policy and Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Gun violence is a public health crisis in the United States and around the world. Death and disability from gun violence affect all age groups, genders, and races. In order to address and prevent gun violence, it is necessary to present a unifying, science-based framework that leverages learnings from prior diseases. This chapter defines gun violence as a complex biopsychosocial disease by framing gun violence as a disease, exploring the biopsychosocial aspects of gun violence, and then

This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. S. Kohlbeck · S. Hargarten (*) Comprehensive Injury Center, Medical College of Wisconsin, Milwaukee, WI, USA e-mail: [email protected]; [email protected] L. Pederson University of Wisconsin-Madison, Madison, WI, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_308

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using the public health approach to violence prevention as a means of applying the biopsychosocial disease framework. Haddon’s Matrix is also introduced as a means to planning gun violence prevention strategies. The biopsychosocial disease framework can facilitate the development, implementation, and evaluation of comprehensive evidence-based programs and policies on the local, state, and national levels, which will ultimately save lives and restore communities. Keywords

Gun violence · Biopsychosocial disease · Public health · Prevention

Introduction “Firearms can’t ensure safety in the society, only open arms can.” –. Abhijit Naskar, The Constitution of The United Peoples of Earth.

Gun violence is a major, and rising, public health crisis in the United States and around the world. Gun violence accounts for more than 38,000 deaths and an estimated 100,000 injuries per year in the United States (Hargarten et al. 2018). Globally, deaths from non-conflict-related gun violence are estimated to be in the range of 250,000 deaths or more per year (Grinshteyn and Hemenway 2019), representing a major global public health burden. Bullets and the guns that carry them are the injury mechanism most frequently causing homicides and suicides. In fact, in the United States, most gun violence deaths are suicides (Xu et al. 2018). Death and disability from gun violence are tragic outcomes, affecting all age groups, genders, and races. In order to reduce and prevent these tragedies, as has been done with vexing challenges such as HIV/AIDS, we need to apply the sciences of medicine and public health, framing the complex problem of gun violence around a unifying framework. This is a unifying framework which provides the scientific underpinning that informs and evaluates gun violence prevention programs and policies. This chapter will present one such framework by examining gun violence as a complex biopsychosocial disease. The chapter begins with a discussion of the application of the disease model to gun violence and then expands to include biopsychosocial considerations of this disease. We will review in detail the biological, psychological, and social components of gun violence and then apply that framing to understand how this model can be used to understand and advance gun violence prevention and control. Finally, this chapter will discuss examples of policies and program strategies that address biopsychosocial risk for gun violence perpetration and/or victimization.

Gun Violence as a Disease The disease model has been applied to investigate and understand acute and chronic health conditions since the second half of the nineteenth century. In the field of epidemiology, the disease model informs the epidemiologic triad, the

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three components of which include the host, the agent, and the environment. The host is the person affected by the disease; the agent is a virus, bacteria, or other disease-causing entity being transmitted to the host; and the environment is the context in which the disease occurs. Environment can encapsulate the physical environment, the social environment, or the policy environment. Another critical component of this model is the vector. The vector is the vehicle that transmits the agent to the host. The disease model can be applied to acute and chronic diseases alike. For example, the disease model has been applied to understand the Zika virus, a biologic agent of disease. Epidemiologic investigation has discovered that the original host of Zika was the macaque monkey and that the virus had the potential to affect humans as well (Paixão et al. 2016). A 2007 outbreak of Zika affected hundreds of residents on the island of Micronesia (Duffy et al. 2009). This outbreak led to an investigation into the vector of this disease, which carried the Zika virus itself to these residents, and was determined to be a suburban-urban-dwelling mosquito (Duffy et al. 2009). The agent causes multiple physical changes to the host, including fever, a rash, and conjunctivitis, and these physical changes can be particularly damaging to fetuses who are affected in vitro (Moore et al. 2017). The environment plays a role in this disease as well, for example, the effects of the 2015–2016 El Niño phenomenon, which favored mosquito biting rates and lowered mortality rates of the specific mosquito vector types which allowed for Zika to proliferate in the Americas (Caminade et al. 2017). Understanding how the host, agent, and environment interact is important for disease management and prevention. In the case of the most recent outbreak of Zika, a warning was issued to pregnant women to avoid certain areas of the world most impacted by Zika, in order to protect their unborn children. While there is no vaccine against Zika, understanding this strain of the virus helped to identify the mosquitoes (vectors) who were likely carriers of the virus. And, the environment in which the virus proliferates could be modified as well. Environment-focused prevention strategies include the installation of mosquito netting in sleeping areas, eliminating standing water, and using window screens (MacDonald and Holden 2018). In the same way, the disease model can be applied to gun violence. The host in this disease is the person affected by the violence; typically, this is the victim of violence, but it can also mean the perpetrator of violence. The physical agent of disease is the kinetic energy of the bullet that is carried in the gun (the disease vector) and transmitted to the host. The environment includes the physical, social, policy, and community environment in which gun violence occurs. These public health components of gun violence vary depending on each event, but as epidemiologists examine this disease, patterns begin to emerge, and these patterns signal opportunities for intervention and prevention. In addition to providing a platform for planning intervention and prevention, framing gun violence as a disease achieves other outcomes as well. This framing places gun violence on a science-based footing alongside other disease processes. It also shifts perception of gun violence as an “unavoidable tragedy” to a preventable disease. Framing gun violence as a disease challenges myths about this disease such

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as, “Guns don’t kill people, people kill people.” When placing gun violence in the disease framework, we see that the agent, carried by the vector, is what kills. This science-based framework takes gun violence out of the political arena (Hargarten et al. 2018). Guns don’t kill people, bullets do.

Gun Violence as a Complex Biopsychosocial Disease Gun violence is a biopsychosocial disease: it has a biological component, a psychological component, and a social component. Each component will be explained further in this chapter. The biopsychosocial disease understanding, which has been applied to other diseases such as AIDS (Field 1993), extends our understanding of gun violence. This biopsychosocial understanding posits that there is not one specific cause for gun violence, but rather a complex interplay of factors that varies based on the context of the host and environment. The biopsychosocial model is not new. In 1977, Engel argued the “need for a new medical model” which exposed the limits of a biomedical approach to disease and considered not only the biomedical aspects of a disease, but the psychological and social factors as well (Engel 1977). As a physician himself, Engel argued that the biopsychosocial model provides a conceptual framework and manner of thinking that, “. . .serves to counteract the often wasteful reductionist pursuit of what often prove to be trivial rather than crucial determinants of disease” (Engel 1980). In other words, Engel recognized that several interrelated factors, rather than a biochemical alteration alone, are the cause of disease (Borrell-Carrio et al. n.d.) and that ignoring these other factors would be wasteful. Others have since asserted that the application of the biopsychosocial model is necessary in the face of the increasing fragmentation of medicine into myriad subspecialties, some of which “are not aware of human suffering” (Adler 2009). In this way, the biopsychosocial model has pushed physicians themselves to consider psychosocial determinants of disease and the impacts of treatment. More recently, the biopsychosocial model has been extended to examine the determinants of gun violence. Langman (2017) applies the biopsychosocial model to mass shootings and specifically school shootings (Langman 2017). Some of the factors Langman considers in this model as contributors to school shootings include body issues, past trauma, family patterns, and psychopathology (Langman 2017). This examination of biopsychosocial factors is largely limited to a consideration of the shooter himself or herself, and not of those who are survivors of gun violence, witness gun violence, or live in areas in which gun violence is prevalent. We do know, however, that gun violence has biopsychosocial impacts on the survivors of gun violence, as well as loved ones of those who are killed by gun violence, those who witness gun violence, and those who live in communities where gun violence is prevalent. The following sections detail the biopsychosocial components of gun violence in those who are victimized by gun violence as well as in those who perpetrate gun violence.

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Biological Component of Gun Violence The primary focus of the following sections involves the biopsychosocial effects of gun violence, although some biopsychosocial causes are also discussed. (While unintentional gun discharge is certainly a public health issue worthy of discussion, an investigation into this type of gun-related injury is outside the scope of this chapter, which focuses on intentional gun violence.) The biological impacts of gun violence are arguably the most obvious. In trauma centers around the globe, skilled physicians and other providers attend to the physical injuries that result from gun violence, many of which are fatal. Modern science has provided the tools necessary to save the lives of some of those victimized by gun violence and to mitigate the long-term physical impacts of gun violence. Diseases are often studied in laboratory settings. Bacteria and viruses are examined under a microscope. Although it may not seem immediately obvious, it is possible to study the disease of gun violence in a similar manner. The tool in this investigation is not a microscope, but rather a high-speed video camera. Biomechanics laboratories, through the use of high-speed cameras, have been employed to examine the energy release of bullets and the resulting damage to human tissue. Bullets are the carriers of the physical agent of this disease, kinetic energy. Various calibers of bullets can be fired into blocks of gelatin, which are used as a proxy for human tissue, and a high-speed camera allows for a frame-by-frame examination of the damage caused by these bullets. This damage can be quantified, facilitating a comparison of the damage caused by a variety of bullets, from muskets to bullets fired from an assault weapon. Information from these types of studies are useful for informing treatment (secondary prevention). These studies highlight types of bullets that cause the most damage. (Refer to https://www.mcw.edu/departments/comprehensive-injurycenter/research for more information.) An analysis of homicides rates by caliber suggested that the higher the caliber (e.g., a 40 caliber bullet versus a 25 caliber bullet), the greater the likelihood of death (Braga and Cook 2018). In terms of informing treatment and prevention, knowing the damage that specific bullet types cause can inform how, for example, trauma surgeons approach patients. For instance, if it is known that a certain type of bullet fragments or expands after it enters human tissue, trauma surgeons can take precautions when removing this type of bullet from a gun violence victim. The biological impacts of gun violence go far beyond the initial damage caused by the bullet or the fatal event itself. This is a very serious consideration, as nonfatal gun injuries exceed gun deaths (Wintemute 2015). For those who survive a gun violence event, there are years, and possibly a lifetime, of physical disabilities that must be endured. The most serious injuries, which can range from amputations to spinal cord injuries, can lead to a lifetime of pain, medical expenditures, and diminished quality of life, along with other psychosocial issues (Tasigiorgos et al. 2015). Tertiary gun violence prevention strategies focus on the mitigation of these biologic issues and will be discussed in more detail later in this chapter.

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Basic science investigation has uncovered epigenetic effects of gun violence on those who experience it and those who witness it, insofar as traumatic stress has the ability to alter the physical structure of DNA (Bucci et al. 2016). Exposure to traumatic stress through events such as adverse childhood experiences (ACEs) can result in changes to biological systems that regulate the body’s physiological systems (Bucci et al. 2016). The lasting impacts of traumatic events and stressful living conditions experienced during childhood have been revealed through the study of ACEs, which range from various forms of abuse, neglect, and household dysfunction. Both the mental and physical health outcomes of ACEs have been studied well into adulthood, solidifying the association of their effects throughout the lifespan. Major, singular events such as witnessing or being a victim of gun violence, as well as the long-term impact of having an incarcerated guardian due to gun violence, serve as causes of toxic stress due to gun violence itself. Toxic stress acts on the “fight-or-flight” mechanisms of the brain, otherwise known as the hypothalamicpituitary-adrenal (HPA) axis. Along with several other areas of the brain, the HPA axis plays an important role in processing external stimuli, deciphering what we perceive as a threat and how we respond. With persistent exposure to toxic stress early in life, this axis develops a dysregulated feedback loop and subsequently releases inconsistent levels of cortisol (Purewal Boparai et al. 2018). Cortisol, being the “stress” hormone in the body, plays a crucial role in regulation of negative emotion and self-control. With an altered HPA axis, individuals who experience such stress in adolescence are at increased risk for poor self-control, depression, and anxiety (Juruena et al. 2020), which in turn can lead to behavioral problems later in life (Basto-Pereira and Maia 2019). Gun violence in this frame of reference has a twofold effect, with these resulting physiologic changes then leading to a predisposition for individuals to become victims or perpetrators of gun violence in the future. Thus, these changes act as factors that both result from and can lead to gun violence, forming a vicious cycle. Other findings highlight biologic impacts of gun violence that are intergenerational – the architecture of a fetal brain can be altered in utero by the toxic stress experienced by its mother, potentially as a result of gun violence (Desocio 2018). These emerging findings highlight the importance of a life-course, intergenerational perspective in gun violence prevention, and they also point to potential biological underpinnings for risk of gun violence perpetration.

Psychological Component of Gun Violence The psychological component of gun violence impacts both the perpetrator and the victim alike. In the case of gun-related suicide, this psychological component is particularly important to understand. This section will discuss psychological elements of gun violence in both victims and perpetrators of gun violence, beginning with victims of gun violence. The psychological impacts of gun violence on victims are wide-ranging and welldocumented. Gun violence exposure has been linked with a number of psychological

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sequelae including post-traumatic stress disorder (PTSD), fear, depression, and anxiety (Sadat et al. 2019). Studies of trauma have demonstrated that survivors of gun violence have twice the rate of PTSD as survivors of motor vehicle crashes and 13 times the rate compared to those who experience falls from heights (Reese et al. 2012). The age, race, gender, and other demographic characteristics of the victim can have an impact on the extent of psychological “damage” that is experienced. There are also psychological elements that should be considered regarding those who perpetrate gun violence. It needs to be stated, though, that individuals who live with psychological and behavioral health concerns are typically not perpetrators of gun violence. Individuals living with these concerns are more likely to be victimized by gun violence. (Swanson et al. 2015). The proportion of gun-involved crimes perpetrated by individuals with behavioral health concerns (e.g., diagnosed mental illnesses) is lower than it is for those without behavioral health concerns (Swanson and Feltous 2015). There are certain psychological risk factors, though, that influence gun violence perpetration. One such risk factor is alcohol misuse. One study found that acute and chronic alcohol misuse, including binge drinking and heavy drinking, is positively correlated with risk for perpetrating both interpersonal and self-directed gun violence (Wintemute 2015). Other studies have found that illicit use of other substances, including marijuana, is also a risk factor for gun violence perpetration, in general (Schmidt et al. n.d.). Gun violence perpetration and substance abuse share some of the same risk factors (Reid 2001), but neither behavior necessarily causes the other. However, it is possible that some of the effects of substance abuse, which include impulsivity, increase the risk of gun violence perpetration (Banks et al. 2017). Impulsivity has been explored among individuals with various psychological diagnoses, including bipolar disorder, borderline personality disorder (BPD), and attention deficit and hyperactivity disorder (ADHD). In general, impulsivity among BPD and ADHD are greater than that of the general population and bipolar disorder alone. But when combined with the added effects of ACEs, impulsivity can surpass those with innately higher levels (Richard-Lepouriel et al. 2019). For example, the added trauma of ACEs on an individual with bipolar disorder can raise impulsivity levels to greater than those with ADHD or BPD, which are generally greater than that of bipolar alone. This supports the concept that the psychological impact of cumulative traumatic stress can alter one’s decision-making during such times. It is important to distinguish between the perpetration by an individual who lives with chronic alcohol misuse or a psychological diagnosis and perpetration by an individual without such concerns. In the latter instance, an individual may commit a violent act after drinking alcohol because of alcohol’s effects of reducing inhibition. In this case, the effects of the alcohol itself are a biological component of gun violence. This is in contrast to the psychological effects of chronic alcohol misuse (alcoholism) or a diagnosed psychological disorder. There is, of course, a link between psychological and behavioral issues and gunrelated suicide and mass shootings, although the latter occur much less frequently than the former. Firstly, mood disorders and anxiety are widely considered to be risk factors for suicide, while other psychological risk factors for suicide include serious

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psychological distress (particularly in non-Hispanic white individuals) (Suicide Prevention Resource Center 2013b) and hopelessness (Suicide Prevention Resource Center 2013a). In addition, personality disorders have been considered a major underlying psychological factor among mass shooters. Langman (2017), whose body of research explores the biopsychosocial characteristics of school shooters/ shootings, describes three psychological characteristics that can be used to describe such perpetrators: psychopathic, psychotic, and traumatized (Langman 2017). His descriptions of psychopathic-type are reminiscent of personality disorders like antisocial and narcissistic, highlighting a grandiose sense of self, rejection of morality, and lack of empathy for others. Notes on psychotic-type depict traits related to schizotypal or paranoid personality disorders, along with schizophrenia, where paranoid delusions, hallucinations, and impaired social functioning are prominent. Lastly, a depiction of traumatized-type embodies what many individuals with high ACE score may have experienced. Common threads among their families include parental substance abuse, parental criminal behavior, and various forms of abuse and neglect, supporting the notion that toxic stress in early life leaves a lasting impact on the individual. It should be noted, however, that these psychological risk factors must be considered in the context of a person’s experience. We know that not every person who experiences a mood disorder, personality disorder, or serious psychological distress ends up dying by suicide or is involved in mass shootings. Examining the complex interplay of these psychological risk factors in concert with other potential risk factors (including access to lethal means) will provide a more accurate assessment of risk for gun violence.

Social Component of Gun Violence The effects of gun violence on society and the societal-level risk factors for gun violence perpetration and victimization are many. This section will outline the social components of gun violence at the individual level, the interpersonal level, and the community level. Our definition of “social,” for the purposes of this section, is broad and inclusive. A person’s social network has an impact on his or her risk for gunshot injury as a result of interpersonal violence. Papachristos et al. (2012) found that an individual’s probability of experiencing a bullet injury is associated with that individual’s social network distance to other gunshot victims (Papachristos et al. n.d.). This means that individuals who associate with gunshot victims are more likely to sustain a gunshot injury themselves. Additionally, research has demonstrated that gang members, and specifically adolescent gang members, are more likely to be victims of violence, including gun violence, than non-gang members (Taylor et al. 2007). In terms of gun violence perpetration, some studies have demonstrated that observing intimate partner violence as a child can increase the risk of future violence, including gun violence, perpetration (Roberts et al. 2010). Social networks also have an impact on the risk of gun violence perpetration. In fact, exposure to a gun violence

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victim or perpetrator in one’s social network can increase that individual’s risk of future gun violence perpetration (Tracy et al. 2016). In terms of intimate partner violence, access to a gun increases risk of homicide in abusive intimate partner relationships (Goodyear et al. 2019). For children, a social support network is imperative to develop safe and healthy relationships. This is of particular importance when such individuals have experienced any degree of ACEs. Wan et al. (2018) found that the combination of low social support and a high degree of ACEs increase both suicidal ideation and attempts across genders (Wan et al. 2018). With access to lethal means, this association raises concern for suicide rates among this population. With over half of the general population having at least one ACE (Hughes et al. 2017), this likely constitutes a considerable percentage of individuals to target when developing policy changes and early intervention strategies. Gun violence has roots in social issues and contributes to social problems. Gun violence in neighborhoods can break down social cohesion, undermining residents’ ability to maintain effective social control and achieve common goals (Hardiman et al. 2019). When thinking about gun violence as a disease, we can conceptualize the social forces of oppression and severe neighborhood deprivation as contributing to the toxic environments that cause disease (Greene 2018). Social factors such as social isolation can contribute to suicide and particularly when guns are readily available in environments such as rural settings. While the biological, psychological, and social components of gun violence presented here are not intended to be an exhaustive listing, they are meant to illustrate the complexity of gun violence as a disease. The components presented include risk factors for victimization and perpetration of gun violence, as well as the biopsychosocial impacts of gun violence. The next section turns to gun violence prevention, which incorporates this biopsychosocial disease framing.

Gun Violence Prevention and Haddon’s Matrix As discussed earlier in this chapter, gun violence is a public health disease burden requiring public health-oriented prevention programs and policies. Public health divides prevention into three levels (World Health Organization 2019): 1. Primary prevention strategies involve improving the overall health of the population and preventing the occurrence of the disease. 2. Secondary prevention strategies involve early detection of a disease to prevent it from advancing. 3. Tertiary prevention strategies involve improving treatment and rehabilitation to mitigate the effects of a disease on an individual who has been affected. Gun violence prevention takes place across this prevention spectrum. Primary prevention involves population-level program and policy strategies. Secondary prevention involves early intervention of gun violence patients with appropriate

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attention to the risk of subsequent gun violence. Tertiary prevention includes interventions that mitigate the long-term biopsychosocial impacts of gun violence. Building on and incorporating the three levels of prevention, the Centers for Disease Control and Prevention (CDC) presents a framework for violence prevention (Centers for Disease Control and Prevention 2019). This approach, which is rooted in the scientific method, involves the core public health discipline of epidemiology, evaluation, and the development of policies and programs that improve the public’s health. The public health approach to violence prevention includes four steps: 1. Define and Monitor the Problem: Understanding the who, what, when, where, and how associated with violence. 2. Identify Risk and Protective Factors: Risk factors are those biopsychosocial characteristics that increase the chance a person becomes a victim or perpetrator of violence, and protective factors are biopsychosocial characteristics that protect a person from becoming a victim or perpetrator of violence. 3. Develop and Test Prevention Strategies: Piloting and implementing violence prevention programs and policies and evaluating them. 4. Assure Widespread Adoption: Disseminating findings from violence prevention program evaluation to facilitate broader implementation of evidence-based strategies. An understanding of the public health approach to gun violence prevention is useful, as this approach is used by public health agencies and others engaged in gun violence prevention. This approach is also consistent with an understanding of gun violence as a complex biopsychosocial disease. These same four steps can be applied to any disease burden, just as the CDC applies them to violence. Public health is a key stakeholder in violence prevention, along with law enforcement and other sectors of civil society. The discipline of injury prevention also offers strategies to plan gun violence prevention. William Haddon Jr., a physician and leader in motor vehicle crash research in the 1960s and 1970s, developed what is now known as Haddon’s Matrix. This matrix combines the basic principles of public health prevention to the disease model into a cohesive framework that can be used to plan and implement and evaluate injury prevention policies and programs. Haddon initially applied his matrix to motor vehicle crash prevention, but the matrix can and has been applied to many types of injury (Runyan 1998). Haddon’s Matrix is organized into a table, as shown in the table below. Along the left side of the matrix are the three levels of prevention (in this case, referred to as pre-event, event, and post-event). The top of the matrix includes the three components of the disease model: the host (the individual affected by the disease), the agent of injury (in the case of gun violence, the kinetic energy release of the bullet), and the environment, which is inclusive of the physical and social environment. Prevention planners can then use this matrix to devise strategies to prevent injury that consider each facet of the disease model across the prevention spectrum.

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Haddon’s Matrix can be applied to gun violence prevention. Understanding the biopsychosocial components of gun violence facilitates a consideration of the multiple risk factors that can be targeted for prevention at the pre-event, event, and post-event stages. Treating all facets of the disease of gun violence across all three levels of prevention may enhance comprehensive violence prevention programming. The table below displays Haddon’s Matrix, populated with potential strategies aimed at preventing gun violence. These strategies are further detailed in the next section. Table: Haddon’s Matrix Host Universal screening for gun violence risk Screening for ACEs in primary care settings

Agent/vector Gun lock distribution programs

Event

Extreme risk protection orders (“red flag” laws)

Postevent

Hospital-based intervention programs aimed at reducing retaliatory violence Early intervention programs for those identified as having high ACE scores

Smart gun technology Low capacity magazines Improvement of ability to trace firearms used in gun violence incidents

Preevent

Environment (physical and social) Social norms campaigns aimed at decreasing the acceptability of gun violence Widespread early intervention programs to improve social networks and reduce ACE impact Reduce stigma toward mental health management Violence interruption programs

Ensuring that public spaces have adequate space for access by emergency vehicles if necessary

Examples of Gun Violence Prevention Policy and Practice The pre-event strategies presented in the example matrix are population-level strategies aimed at primary prevention. Universal screening programs for risk are sometimes employed as a primary prevention strategy for suicide. For example, a universal screening program could involve the administration of a suicide screener, such as the PHQ-9, to all patients presenting to a primary care clinic. Children can also be screened for ACEs through a similarly implemented screener to identify youth at increased risk for adverse outcomes. Similarly, gun lock distribution programs are frequently employed as a primary prevention strategy for gun violence which are aimed at decreasing unintended access to a firearm. Gun locks are useful in homes with teens, as they provide a barrier to unauthorized use of a gun that is not otherwise secured (e.g., in a gun safe or lock box). A pre-event strategy that is aimed

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at the social environment may involve a campaign that is aimed at dismantling and changing norms that suggest that gun violence is an acceptable method of conflict resolution. In addition, after school and mentorship programs can help build positive social networks in safe environments for adolescents, especially those with high ACE scores. These pre-event strategies can target at risk populations, or general populations, regardless of their risk profile. The event phase strategies presented in the example matrix begin to consider individual-level risk factors. Extreme risk protection orders (ERPOs – sometimes referred to as “red flag” laws or risk-based gun removal laws) are policies that are meant to separate guns from people at risk of harming themselves or others (Swanson et al. 2017). ERPOs provide a mechanism through which family members or loved ones of a person who is at perceived risk of harming himself or herself or others can obtain (through law enforcement) a warrant to remove guns from the home of the person at risk. This is a temporary order which provides an opportunity for the at-risk person to obtain help at the time of a crisis, and this mechanism is further established to allow for the transfer of the gun back to the owner after the crisis has passed. Initial research is demonstrating that these types of laws may be effective in preventing gun violence, specifically suicide and mass shootings (Swanson et al. 2017). An example of an event level strategy targeted at the agent of gun violence injury – the kinetic energy of the bullet – is smart gun technology. Smart guns, sometimes called personalized guns, are designed so that the bullets can only be discharged by an authorized individual (Wolfson et al. 2016). This technology can include grip recognition, which ensures a gun will not fire if the grip of the user does not match that of the authorized individual, fingerprint recognition, or radio-frequency identification (RFID) tags, which emit identification data through radio waves to a magnetic ring or bracelet that is worn by the authorized user (Rotter and Anrig 2012). In this case, the weapon would not fire if the ring or bracelet is not in range. Another example of this event strategy is limiting the capacity of magazines for rifles. Policies restricting large capacity magazines are in place in several states, and some initial studies suggest that this reduces the number of victims in mass shootings (Klarevas et al. 2019). An environmental strategy that can be employed to prevent gun violence at the time of the event is violence interruption, a time-sensitive behavioral intervention. One example of this type of program is the violence interruption program that has been implemented to reduce homicides in Jamaica. The VIP uses trained violence interrupters to determine potential or recent shooting events, identify individuals and/or groups at highest risk of involvement in these events, and interrupt these events through mediation (Unicef 2016). This type of strategy is modeled after the Cure Violence Model and also involves efforts directed at influencing and changing social norms in high-risk communities (which is a pre-event, environment tactic) that perpetuate violence and the use of guns (Butts et al. 2015). However, evaluation findings regarding this model are mixed, so additional research at the community and individual levels is needed.

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Post-event strategies are meant to mitigate the impacts of gun violence that has already occurred. One such strategy that is aimed at the host is a hospital-based violence intervention program. Hospitals and trauma centers are skilled at addressing the biological needs of gunshot wound patients. However, when an individual has been injured as a result of gun violence and they are admitted to the hospital, hospitals have an important opportunity and responsibility to intervene in a manner that supports the psychosocial elements of gunshot wound survivors as well. This could involve providing psychological services, while the individual is an inpatient as well as offering post-discharge follow-up and linkages to community-based resources. Evaluation results from hospital-based violence intervention programs indicate that they may prevent violent reinjury, violent crime, and substance misuse after the initial gun violence event (Purtle et al. 2013). The trauma team now consists of a trauma surgeon, a health psychologist, and a social worker. In a similar light, but targeting children, programs would include early intervention programs for youth identified as having a high ACE score. These programs would be geared toward mitigating the effects of their toxic stress already endured (post-event), to prevent further gun violence perpetration among this vulnerable population. Purewal Boparai et al. (2018) found that among 40 randomized control trials evaluating early interventions on children with ACE exposure, regardless of the setting implemented, there was improvement in the biological components measured (Purewal Boparai et al. 2018). These measurements included cortisol levels, brain development, and epigenetic regulation, among others. While further testing is needed to solidify the impact of these varied interventions have on health outcomes in children, there is promise that such efforts positively impact the biological effects of toxic stress such as gun violence, possibly mitigating the continued perpetration among this population. Another post-event strategy, which is aimed at the agent of injury, is strengthening the ability to trace guns that are used in gun violence events. This is particularly useful when a gun used in a gun violence event had been purchased secondhand. At present, a majority of states do not regulate these purchases (Braga and Hureau 2015) which makes tracking information related to these purchases challenging. This information, however, would be incredibly useful to law enforcement and others engaged in gun violence prevention by being able to specifically target gun traffickers to interrupt unauthorized or illegal gun purchases, thereby potentially preventing future gun violence incidents. One important physical environment post-event strategy involves ensuring that public spaces have adequate access for ambulances and other emergency vehicles should a gun violence event occur. Immediate access to appropriate medical care during acute injury events is essential to mitigating the initial negative biological impacts of the injury. Planning and constructing entrances and exits in public spaces accordingly will help facilitate this access. Alternatively, cities like Philadelphia have adopted “scoop and run” strategies involving law enforcement transport of gunshot wound victims to hospitals. Law enforcement officers typically do not have formal medical training and cannot provide the immediate medical care that

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emergency medical services (EMS) provide, but they may arrive on the scene of a gun violence event sooner than other services and have quicker access to the injured individual. One study of this practice in Philadelphia found no significant overall difference in adjusted mortality between individuals transported to the hospital with penetrating trauma (e.g., gunshot wounds) by law enforcement compared with EMS (Band et al. 2014). These findings suggest that this strategy could be considered as a compliment to EMS transport. These examples demonstrate the utility of a public health approach to gun violence prevention that utilizes a framework like Haddon’s Matrix for prevention planning. A potential limitation of the matrix is that, on its surface, it does not appear to address the many structural factors leading to gun violence victimization and perpetration, which include institutional racism, unequal access to resources, and oppression (Kohlbeck and Nelson 2019). These structural factors are the “causes behind the causes” of gun violence, and addressing them is key in assuring sustained gun violence prevention. Arguably, the environment component of Haddon’s Matrix would encompass these structural causes of gun violence. However, those engaged in gun violence prevention ought to explicitly acknowledge and consider these factors in prevention planning, perhaps by extending the matrix to include a fourth column that focuses on dismantling structures that lead to gun violence.

Case Example Charles was a 22-year-old Black man living in a dense urban environment. He was involved in a neighborhood altercation that resulted in gun violence, and Charles was wounded several times in the shootout. Fortunately, Charles received prompt attention by emergency medical services and was transferred to a Level I Trauma Center, where he underwent a successful surgery and recovery. Several days after the incident, Charles was discharged from the hospital and returned home to his neighborhood. Within weeks, however, Charles abruptly abandoned his home and relocated to another community. This is not an ideal response, as it removes Charles from his current support network and disrupts his life even further. On the surface, Charles’ story appears to be a success. He did not succumb to his injuries. He received the appropriate medical treatment to enable him to return to his life. What this brief story does not outline are the psychosocial aspects of Charles’ life, both before the incident and after, that led to his abrupt relocation. A deeper understanding reveals additional facts. Charles experienced several adverse experiences as a child, even witnessing his uncle being shot and killed when he was 5 years old. In the hospital, Charles’ family visited him several times and encouraged him to retaliate against the person who shot him. In the days and weeks after the shooting, Charles at times experienced moments of extreme fear and anxiety and at other times was disengaged and showed dissociative symptoms. Charles was also an accomplished poet who shared his work regularly in his community. The medical community has become extremely skilled in dealing with the biological aspects of gun violence. Charles’ physical injuries were successfully

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treated. Often what is lacking is treatment for, or even an understanding of, the psychosocial components of a person’s life when they experience gun violence. Perhaps Charles would not have been in the position he was when he was shot, had he been given the opportunity to develop stronger social networks and coping skills as a child after experiencing so much toxic stress. He may not have felt compelled to leave his home had he received proper psychosocial interventions, such as assessment for PTSD or violence interruption, in the hospital setting and immediately after discharge. Perhaps the community would not have lost Charles’ invaluable gift of poetry.

Key Points • Gun violence is a complex, but preventable, public health burden. • Framing gun violence as a biopsychosocial disease provides a unifying, sciencedriven method for understanding this disease burden. • Applying the public health approach to violence prevention, with an eye toward the biopsychosocial causes of gun violence, can identify multilevel and multifaceted strategies for gun violence prevention.

Summary and Conclusion Gun violence in the United States is prevalent, complex, and, hopefully, preventable. Likewise, gun violence prevention requires a thorough understanding of the complex interplay of factors that lead to a risk of victimization and/or perpetration. This chapter has provided the background and supporting information to enable communities and providers to understand gun violence as a complex biopsychosocial disease. This understanding can facilitate the development, implementation, and evaluation of comprehensive evidence-based programs and policies on the local, state, and national levels, which will ultimately save lives and restore communities.

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Suicidality and Interpersonal Violence

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Suicidality and Domestic Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Suicide as Escape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vulnerable Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Suicide Threat as a Tool of Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Risk to Male Perpetrators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interpersonal Murder-Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intimate Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Murder-Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Familicide and Other Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Theories of Murder-Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Abuse and Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Suicides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ACES as Predictor of Adult Suicidality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diathesis-Stress Model of Suicidality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bullying and Suicidality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definitions and Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bullying of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cyberbullying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Workplace Bullying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sexual Abuse and Suicidality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Sex Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Abuse by Clergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Neurobiological Impact of Child Sex Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adult Rape and Sexual Assault . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sex Trafficking and Suicidality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Domestic Homicide, Suicide, and Firearms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Suicidality and Interpersonal Violence – Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Multimorbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Coordinated Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intervention and Assessment of At-Risk Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Protective Factors for Bullied Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Preventative Measures for Child Sexual Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recommendations for Sex Trafficking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevention of Murder-Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Promising Approaches to Suicide Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Further Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

In 2018, more than 48,000 people committed suicide in the United States, which amounts to approximately 129 deaths per day. The rate of suicidality has been increasing for the last decade and in the last 20 years, incidence has risen about 30%. Worldwide, approximately 800,000 people die from suicide every year. The etiology of suicidality is multidetermined, with a preponderance of suicides resulting from various acts of interpersonal violence. Throughout history, diverse societies have exhibited many different attitudes toward suicidality, with rare mention of its definite links to varied forms of violence. This chapter explores potent risk factors for suicide that directly or indirectly involve violence and abuse, such as domestic violence, child abuse, sexual assault, sex trafficking, school bullying, cyber bullying, and in general, those suffering from post-traumatic stress disorder (PTSD) as a result of interpersonal violence. Recent neuroimaging studies found that there are similarities in the brain between decision-making circuits for patients with suicidal ideation and PTSD patients (Barredo J, Aiken E, Wout-Frank M, Greenberg B, Carpenter L, Philip N, Front Psychiat 10(44), 2019). Furthermore, there exists evidence of strong correlations between risks for suicidality and risks for potentially violent behaviors, including firearm prevalence, gang membership, self-harm, and physical fighting. Throughout history, there have been many cases where suicide has been employed as a vehicle for violence, as with murder-suicides in family settings, and war-time suicides. Section “Future Research” focuses on risk mitigation factors. Applications of these topics for both assessment and prevention efforts are presented in order to slow down the current rising trends in suicidality, as well as reduce other forms of interpersonal violence. It is clear that suicide is not only an act of violence toward the self, but also an act that may be rooted in often results from violent and abusive behaviors. Keywords

Suicidality · Ideation · Trauma · Abuse · Domestic violence · Rape · Sexual assault · Bullying · Sex trafficking

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Introduction It is difficult to imagine suicidal behavior without the existence of previous trauma. Simply put, psychological trauma can essentially be reduced to two types of abuse: violations and abandonments. In lay terms, these abusive interactions can be termed too close (the violations) and too far (the abandonments). Abandonments are manifested by death, separation, termination, desertion, jilting, betrayal, and neglect. It is worth noting the frequency of neglect, as it is the most commonly reported act of child abuse. The trauma of violation is demonstrated by such actions as physical abuse, sexual assault, bullying, and corporal punishment. This chapter on suicidality and interpersonal violence primarily focuses on the traumatic violations. Data reveal significant correlations between victims of interpersonal violence and suicide, suicide attempts, and suicidal ideation (Brown and Seals 2019). With severe or chronic exposure to abuse and violence at the hands of a loved one, individuals typically experience shock, fear, betrayal, isolation, depression, helplessness, and hopelessness. These feelings are logical markers on the path toward suicidal behaviors. Additionally, murder-suicides are explored in the service of identifying familial and environmental predictors to help reduce its occurrence. There is a discussion of intermediate factors associating interpersonal violence with suicide, such as depression, marital estrangement, mental disorders, physical health issues, and the preponderance of firearms in the home. Lastly, this chapter highlights applications of this study in order to devise improvements to the practice of both assessment and prevention of suicidality. The ultimate purpose is to create future direction action plans that serve to slow down the current rising trends in suicidality, as well as reduce all forms of interpersonal violence.

Suicidality and Domestic Violence Suicide as Escape From a macro perspective, suicide represents the victim’s escape of last resort from the ravages of domestic violence. The dynamics of domestic violence involve a broad range of behaviors, including physical violence, intimidating gestures, isolation from family and friends, controlling actions, destroying objects, degrading remarks, extreme jealousy, threats of harm, threats to eliminate income, threats to take away children, and the invasive abuses of exacting interrogations, disrespect of personal boundaries, and continual reviewing of emails and cell phone messages. When these dynamics play out over a course of time, the victim most often experiences fear, anxiety, depression, humiliation, aloneness, sense of failure, apathy, entrapment, and eventually, hopelessness. O’Connor and Nock (2014) point to the defeat and entrapment that are hallmarks of the need to escape, which ultimately lead to suicidality. In efforts to avoid or mitigate the next onslaught of abuse from the perpetrator, the victim’s life becomes centered on survival. Instincts for survival hold

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primacy over the freedom to be oneself. Compliance and obsequiousness permeate every vocal expression, every gesture, every intention, and every thought. A sense of personal identity is strictly suppressed and starts to feel as if it is permanently gone. In time, self-awareness of one’s painful situation is a casualty of continuing abuse, and the idea of suicide comes to represent a plausible escape (Baumeister 1990). In chronic or severe cases of domestic violence, victims feel as if they have no one to turn to and no self to rely on. There is increasing urgency and certainty on the act of suicide as the only way out. Interpersonal partner violence has been considered to be a principal and robust correlate of suicidal ideation (Wolford-Clevinger et al. 2017). In a majority of situations, the time frame is brief between the triggering abusive episode and suicidal behaviors. Studies reveal that interpersonal difficulties and conflicts – specifically with a spouse – are common in the six months prior to suicide, as well as in the few days before death (Overholser et al. 2012). Research reveals that the probability of a suicide attempt is increased within 48 h following a negative life event with a romantic partner (Bagge et al. 2013). Though personal and environmental consequences are discussed in the literature, particularly mental disorders and substance abuse, psychological sequelae of domestic violence are highlighted when correlating abuse with suicidality (Cort et al. 2014). O’Connor and Nock go so far as to state that “suicide is perhaps the cause of death most directly affected by psychological factors, because the person makes a conscious decision to end his or her own life” (2014, p. 73). Of all forms of domestic violence, psychological abuse is more strongly linked with suicidal ideation than physical assault (Wolford-Clevinger et al. 2017). The psychological impact on victims of domestic violence is well-documented. Lenore Walker was among the first researchers to study the psychology of domestic violence victims. Walker (1985) focused on the learned helplessness and hypervigilance symptoms of PTSD. Hypervigilance keeps victims on constant alert for anticipated violent episodes, ensuring that they are never at rest. Domestic violence, including physical and psychological abuse, has been linked with the development of PTSD (Babcock et al. 2008). A recent study of the brain found that there are particular neurobiological decision-making circuits in PTSD patients that correlate with suicidality (Barredo et al. 2019). It is important to note that the link between PTSD and suicidal behaviors is present regardless of the type of trauma endured. In their work on the identification of suicidal risk factors for victims of domestic violence, Munroe and Aitken (2019) specified learned helplessness and isolation. Learned helplessness, defined as the powerlessness, without possibility of escape, that occurs when repeatedly confronted with aversive stimuli, merits frequent mention in these studies. The diathesis model of suicidality posits that both environmental stressors and genetic or biological predispositions come together to manifest suicidal behaviors. The “cry of pain” model is a type of diathesis suicide model that is encapsulated by Van Heeringen and Mann (2014) as: (1) hypersensitivity to signals of defeat; (2) perception of no escape; (3) perception of no rescue possible. Taken together, these three cries of pain can be abridged as hopelessness. In a review of literature focusing

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on the association between PTSD and suicidal behavior, it was determined that “hopelessness, defeat, and entrapment” are causal factors for suicidality (Panagioti et al. 2009). The feeling of hopelessness has been found to be a common trait in suicidal patients (Van Heeringen 2000). Hopelessness can be viewed as a state of mind that is bereft of solutions to one caught in the on-going, ever-present problem of domestic violence. When that state of mind is manifested behaviorally, the result may be suicide. Perhaps, the most harmful, intimidating type of psychological abuse most closely correlated with suicidality is coercive control over one’s partner (Williamson 2010). Dutton and Goodman (2005) brought attention to the severity of coercive control in their discussion of the dynamics of domestic violence. Coercive control domestic violence involves absolute demands for power and dominance, along with enforcement of those demands by intimidation. This form of abuse places the victim squarely in an unescapable position. At that point, suicide may seem like a source of relief.

Vulnerable Populations As would be expected, the most vulnerable are at increased risk of suicidal behaviors. A report of the US Surgeon General and the National Alliance for Suicide Prevention outlines a National Strategy (2012) that identified high-risk individuals, included those with medical conditions and mental disorders. Health problems and relationship conflicts are among the five most common life stressors identified as triggers of suicide attempts (Overholser et al. 2012). Studies reveal significantly more hospitalization for women involved in violent relationships, suffering from diagnoses such as psychiatric conditions, physical injuries, poisonings, and attempted suicides (Haqqi 2008). The elderly is considered to be vulnerable to increased suicidality risk. The typical profile for elderly individuals exhibiting suicidal behaviors reveals males in their 1980s, using a firearm, either involved in an abusive relationship or being the long-term caretaker for a spouse with worsening health problems (Salari 2007). Though suicide is frequently the primary motive, there exists substantial evidence of spousal homicide preceding the suicide (Salari 2007).

Suicide Threat as a Tool of Abuse While it is well established that suicide is a possible consequence of domestic violence, the threat of suicide can be used as a form of domestic abuse. In predatory fashion, domestic abusers resort to any means to achieve control over their partners. Tools used to manipulate and control include physical violence are threats of harm, threats to take the children, threatening looks and gestures, extreme jealousy, insistent interrogations, harsh criticisms, and guilt. Efforts to induce guilt reach their apex with the threat of suicide. When threatened by a spouse’s suicidal

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behavior, the victim often experiences fears of immense loss. The purported losses include family income and support, as well as the loss of the other parent to the children. Due to the fixed human tendency for attachment, notwithstanding the circumstances, the victim is psychologically attached to their partner. Perhaps counterintuitively, there exists a realized loss of the person they have invested so much of themselves into.

Risk to Male Perpetrators It can be implicit that, in addition to the harm done to victims of violent domestic crime, their (nonsociopathic) complementary perpetrators must also be suffering psychological pain both before and after their abusive actions. Studies indicate that in addition to victims of domestic violence, male perpetrators are at greater risk of suicidal ideation and suicide attempts than nonoffending males (Wolford-Clevinger et al. 2017). Once designated by the courts, their community, and greater society as a domestic violence abuser, these men typically suffer from shame, disconnectedness, self-hatred, perceived burdensomeness, and thwarted belongingness. Upon arrest, the serious interpersonal and legal problems they are faced with compound the depression and hopelessness that they experience. Life-long tendencies toward aggression and impulsiveness in many perpetrators exacerbate the risk for suicidal behaviors.

Interpersonal Murder-Suicide Intimate Partners Murder-suicide is a relatively rare event, but it is considered a quite serious form of interpersonal violence, due to the multiple victims involved, the degree of secondary victimization that occurs, and the shock created in greater society (Liem 2010). The killing of an intimate partner is the most common type of domestic homicide and also the most frequent type of murder-suicide. Approximately 75% of murdersuicides involve killing a current or former significant other (Logan et al. 2013). Typically, perpetrators suffer from some form of mental illness, with depression cited most often, and to a lesser degree, thought disorders (Bourget and Moamai 2000). Males are much more likely to commit murder-suicide than females. One of the common triggers involves rejection by a female in marriage or a boyfriend– girlfriend relationship, with withdrawal, separation, and estrangement being proximate causes (Palermo 1994; Eliason 2009). It is the inability to accept the loss that drives the murderer. Some have specified the cause as extreme dependency or overenmeshment with the spouse, with no clear recognition of boundaries (Auchter 2010). The term, “extended suicide,” has been used to connote the lack of boundaries in the psyche of the killer with regard to his spouse (Palermo et al. 1997).

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The commission of murder-suicide is directly linked with prior domestic violence in the relationship. Perpetrators are typically motivated by fear of exposure of their violent actions or are driven by impulsiveness fueled by anger or paranoia (Liem 2010). As documented in the literature on domestic violence, the most elevated risk of homicide for women is in the early stages of separation. It has been suggested that the first two months of separation represent the highest risk for murder-suicide (Bourget and Moamai 2000). Controlling behavior during the relationship reaches its extreme with murder-suicide, which symbolically is the ultimate control over the lives of the couple. Murder-suicide perpetrated by the elderly frequently has its origin in the failing health of one member of the relationship, with complementary caretaking by the other. Over time, this arrangement creates a special bond between the two, and further decline of health threatens the dissolution of this unit (Cohen et al. 1998). This threat of abandonment seems to be the primary trigger for murdersuicide.

Child Murder-Suicide Among developed nations, the United States has the world’s highest rate of child murder, with the most common perpetrator being the child’s parent (Resnick 1969). The killing of a child (filicide) followed by a suicide is the second-most common type of murder-suicide, accounting for about 14% of murder-suicides (Logan et al. 2013). The primary motive is reported to be the parent’s own self-destruction. The killing of the child is motivated by the idea that with their death, there would be no adequate caretaking for the child (Liem 2010). At times, the perpetrator’s primary target is the estranged spouse, and the child is then used as a means of hurting and abusing the spouse. As one might expect, intimate partner violence is the common antecedent of murder-suicide involving a child (Logan et al. 2013). Abuse between the couple was found to be a frequent commonality whether the perpetrator was male or female. Generally, females commit about one-half of singular spousal homicides. Regarding murder-suicide, males were almost two times as likely as females to commit filicide before their own suicide (Eliason 2013). When comparing child homicide with child murder-suicide, it was found that older parents were more likely to commit suicide following filicide, and that genetic parents were more likely than step-parents to take their own lives (Logan et al. 2013). Once again, depression is the most prevalent mental disorder reported in all perpetrators. Psychotic disorders were frequently found in women who killed their children or murdered multiple victims. While males committed over 90% of all murder-suicides, females committed just over 50% of child homicides (Logan et al. 2013). An influential framework used to account for perpetrator motives in child homicide includes five distinct categories: (1) altruism, the wish to relieve children from real or imagined suffering; (2) psychosis, severe mental illness involving delusions or hallucinations; (3) unwanted child, lack of wish to be a parent, or lack

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of tolerance for the child; (4) child abuse, death of child usually unintentional; (5) revenge against current or former spouse, extended means of domestic violence (sometimes occurring during custody disputes) (Resnick 2016).

Familicide and Other Types Familicide refers to the type of murder-suicide where the perpetrator kills multiple family members, which can include spouses, children, parents, siblings, grandparents, or other close relatives. It is quite rare for females to commit familicide, as the most common profile for offenders is a Caucasian male in his 30s or 40s (Liem 2010). Primary motives for a male perpetrator are the feelings of loss of control over his spouse and feelings of failure to provide for his family. When financial problems are in play, the perpetrator may feel that he is protecting his family from future ruin (Liem et al. 2013). This ostensibly altruistic motive has been termed “suicide-byproxy,” wherein the perpetrator/father views the familicide as a lethal solution to his problems (Resnick 2016). When motivated by the loss of control over his spouse, the perpetrator/father is reacting to his wife’s threat of estrangement, and then acts out by killing her and the children, who are viewed as an extension of her. This is called “murder-by-proxy” (Resnick 2016). The commonality with both types of familicide, involving spouse and children, is the loss of control. With suicide-by-proxy, the loss is over the fate of the family. With murder-by-proxy, the loss concerns the fate of the marriage. It is extremely rare for suicide to follow the killing of a parent (parricide). Psychologically, unresolved separation-individuation issues are at work and the death of the parent would “solve” that problem. There is also extreme infrequency for suicide to follow the killing of a sibling (siblicide). In the mind of the enmeshed perpetrator, the death of the sister or brother represents a symbolic killing of part of the self, thereby rendering suicide unnecessary.

Theories of Murder-Suicide The strain theory is rooted in Emile Durkheim’s concept of “anomie,” developed at the end of the nineteenth century (Jones 1986). In the context of suicide, anomie refers to the difficulty to adjust to the rapid social changes that tend to recur in societies. Specifically, the strain theory posits that some of the options that arise to deal with social changes are dysfunctional, which include choices of retreat and rebellion (Liem 2010). Retreat reaches its extreme form in the act of suicide, while rebellion attains its extreme in the form of murder. When faced with seemingly unsolvable rapid changes that affect the fate of one’s family, there is an increased probability that the “head” of that family will commit murder-suicide. Durkheim proposed an alternate theory for suicidality centered around his concept of social integration, which describes the various ways that people feel connected to their society (Jones 1986). Suicide, and particularly homicide-suicide,

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is more likely to occur with the presence of major disconnects from one’s society (Liem 2016). As mentioned in the discussions of intimate partner homicide and familicide, the spouse’s threat of leaving or separation may exacerbate the alreadyexistent disconnectedness in the perpetrator and push them over the edge to murdersuicide. Psychodynamic theory, as fashioned by Freud, posits that suicide is rooted in an impulse to commit murder that is directed inwardly toward the self (Mizen and Morris 2007). The hated other, the spouse, is introjected, and in this context, suicide represents an act of murder toward the other. Additionally, as Freud theorized, a harsh superego is responsible for killing the self as a punishment for killing the spouse. Psycho-evolutionary theory postulates that it is the woman’s reproductive fitness that is at stake. A controlling male partner feels that he is in charge of the woman’s reproductive capacity. When the woman threatens to end the relationship, the male would then feel that he is in the cuckold position. At that point, he questions whether current or prospective children are his. From a psycho-evolutionary perspective, the woman’s threat to leave is tantamount to a threat that his genes will not be passed on. The murder of the woman can then be viewed as killing off any possibility that his rival’s genes will be passed on to offspring. Magical thinking is the belief that an individual’s thoughts, ideas, words, or actions influence events in reality. The individual presumes that their personal, inner experience can create events in the external world. With murder-suicide, as is the case with suicide following the nonhomicidal death of a spouse, magical thinking lends itself to the idea that there will be a reunion (in heaven) with the departed spouse.

Child Abuse and Suicide Child Suicides Compared with the general population, child victims of parental abuse and adult victims of domestic violence are both more at risk for suicidal behaviors. For victims of spousal abuse, it was posited that suicide may well represent escape from a seemingly inescapable situation. In elementary terms, suicide can then be conceived as “don’t hurt me” or “don’t see me.” For children bent on suicide, the statement might read, “see me.” Though physical and sexual abuse in childhood are definite risk factors, it is hypothesized here that neglect and lack of support may be primary precipitating factors for very young children. Conversely, studies show that perceived social support is a significant mediator of the relationship between child abuse and suicidal ideation (Bahk et al. 2017). Forms of child neglect include abandonment, ignoring, rejection, lack of affection, lack of interest, being repeatedly told to keep quiet, being told you are unwanted, pretending that you are not there, and restricting your ability to play with others. Under these conditions, feelings of

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worthlessness, isolation, aloneness, and helplessness are quite palpable for the child. Suicide may represent the wish to finally be seen. Studies confirm that for both children and adolescents, relationship problems are principal precipitating factors for suicidal behaviors, though for younger children there exist some correlation between an ADHD diagnosis and suicidal behaviors (Sheftall et al. 2016). Principal circumstances that trigger younger children involve parental conflict, while adolescents are more likely to be prompted by conflicts with friends and romantic interests. It was found that for older children, alcohol consumption or psychopathology triggered suicide attempts, while for children under age 14, difficulties with parents were the main precipitant (Soole et al. 2015). Both children and adolescents tend to act with impulsiveness, which is a common trait of suicides in minors. Hence, many studies have focused on precipitants in the few days before death, and a frequent finding is conflict with parents and other family members (Holser 2012). While neglect and parent–child conflict may be driving forces for young children, physical and sexual abuse are the most significant risk factors for both suicidal ideation and suicide attempts in adolescents (Miller et al. 2013). Overall, there is evidence of a “strong association” between negative childhood experiences and increased likelihood of child and adolescent suicidal behaviors (Dube et al. 2001). By and large, younger children have not developed adequate coping tools, and so they are particularly vulnerable when confronting their own experiences of abuse, as well as witnessing abuse between parents.

ACES as Predictor of Adult Suicidality Negative events are major stressors that are inevitable during the course of life and have a cumulative effect when considered with other stressors. When current negative life events are superimposed on the experience of similar events in childhood, the result is often termed chronic stress and has been shown to increase the probability of suicidal behaviors (Wasserman 2016). Adverse childhood experiences comprise negative life events that occurred during childhood. They include substance abuse, parental divorce, depressed affect, mental illness in the family, and parental incarceration. A seminal ACES study revealed that approximately twothirds of adult suicide attempts can be attributed to traumatic or abusive childhood experiences (Dube et al. 2001). Any form of child maltreatment has been shown to be a clear and significant predictor of suicidal behavior (Goldberg et al. 2019). The experience of complex childhood abuse, described as the accumulation of negative life events that are abusive in nature, is associated with a particularly high risk for suicide attempts in adults (Angelakis et al. 2019). Bahk et al. (2017) found evidence of a link between childhood trauma, particularly maltreatment, and later suicidal ideation. Indeed, many studies confirm that childhood maltreatment is associated with increased probability of suicidality in both children and adults.

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Specifically, studies show that suicide attempts were approximately 2½ times more likely for individuals who experienced physical abuse as children, with the same approximation for those who experienced emotional abuse and neglect (Angelakis et al. 2019). The same study revealed that adults who endured multiple forms of abuse as children were 5 times as likely as the general population to attempt suicide. Experiencing even one ACE increases the probability of both depression and suicide in adulthood (Merrick et al. 2017).

Diathesis-Stress Model of Suicidality Diathesis-Stress is an explanatory term used to describe psychological disorders as resulting from interactions between environmental stressors and predispositional, biological vulnerabilities. Specifically, with regard to suicide, early life adversities, such as child maltreatment, often have lasting effects on neurobiology. Post-mortem studies have indicated links between childhood abuse and abnormalities in brain circuitry and neurochemistry (Van Heeringen and Mann 2014). Various types of child abuse, whether physical, sexual, or psychological in nature, are universally recognized as negatively affecting brain development (Konopka 2015). A clear example of damaged neurochemistry in the developing child is the depleted serotonin neurons in the cortical regions of the brain. Serotonin deficiency has been associated with depressed mood, low self-esteem, impulsivity, and self-directed aggression (Carballo et al. 2008). When activated by current life stressors, existing biological vulnerabilities become especially pronounced, and hence more likely to be acted out. These actions may well result in suicidal behaviors.

Bullying and Suicidality Definitions and Types When reviewing dictionaries, clinical references, or lay usage, the word “bullying” bears several common terms, including control, intimidation, aggression, overbearing, persistent, threat, coercion, power, force, harassment, manipulation, assault, fear, and discomfort. Types of bullying vary with context and culture. There are six types of bullying behavior recognized in our current society: school, workplace, political, military, hazing, and cyberbullying. A consideration of the different types of bullies reveals numerous descriptors. Bullies can use verbal, physical, psychological, authoritarian, or legal means to achieve their ends; they may act impulsively, forcefully, deceptively, or sadistically; and they may be motivated by stress, narcissism, revenge, or their own victimhood. The literature shows that whatever the means or motivation, the victims of bullying, the bullies themselves, and even bystanders often suffer psychological, relational, physiological, and economic damage (Hertz et al. 2013). In many cases, the damage may last a lifetime.

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Bullying of Children Individually and societally, bullying has been shown to be both prevalent and harmful in terms of both immediate and long-term effects. Generationally, involvement in bullying behaviors frequently connotes suffering violence as a child and perpetrating violence later in adulthood. Though the consequences are detrimental for victims, bullies, and witnesses, it is the victims of bullying who suffer the most damage (Hertz et al. 2013). However, research reveals that whether one is a bully or a victim of bullying, the rates of suicide ideation and suicide attempts are 3–5 times higher than for uninvolved youth (Espelage and Holt 2013; Zuckerman 2016). The same study shows that the highest rates for suicidality are measured in youth who have experienced both sides, being victim and perpetrator of bullying behavior. The tendency for victims of bullying is to blame themselves for the abuse. Bullied children often become depressed and anxious, and suffer from low self-esteem, sleep problems, health issues, and poor school performance. Studies reveal that children who are victimized by physical and sexual abuse deal with very similar issues (Zuckerman 2016). Taken together, these consequences of child victimization can prove to be overwhelming, and then the path to suicide becomes a plausible one. In a study of children aged 10–17, it was found that the most common precipitating factors for suicidal behaviors were recent crises, relationship problems, mental health disorders, and school problems (Karch et al. 2013). Though the study showed just one of eight students with school problems to be directly related to bullying, it is apparent that recent crises, relationship problems, and mental health disorders are associated with bullying. There exists a strong link between bullying and suicidal behaviors, though depression and delinquency typically play roles as mediating factors (Holt et al. 2015; Espelage and Holt 2013). Child victims of bullying are more likely than perpetrators or bystanders to have suffered from physical abuse in their families and more likely to have witnessed violence between their parents. In keeping with the ACES study, the accumulation of adverse experiences, characteristically traumatic in nature, increases the probability that the bullied child will experience suicidal ideation and suicidal attempts.

Cyberbullying Cyberbullying is a growing problem in the United States, especially for the youth. The ubiquity of opportunity is evident in the fact that the internet provides 24/7 accessibility, and an estimated 95% of children are online and at least 75% access the internet from their mobile device (Hinduja and Patchin 2014). The potential pool of victims, perpetrators, and witnesses is limitless. The obvious appeal of cyberbullying is the relative anonymity that it provides. Both children and adults who would not normally bully others in-person feel a sense of freedom and protection when acting over the internet. Cyberbullies hide their identity using anonymous email addresses and pseudonymous screen names. Victims may not know who the bully is, or the reason that they are targeted. The hurt caused can feel at least as devastating as

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in-person bullying due to online posts or photos going viral. The now-damaged reputation of the victim can be easily accessed by a multitude of people in one’s school, neighborhood, city, or in the world. Theories of wartime aggression reveal that the likelihood of committing excessive damage to victims is increased by the anonymity of the attack, as opposed to situations where the enemy is confronted eye-to-eye. With cyberbullying, typing words appears to be a more conveniently cruel form of attack than the face-to-face spoken word. The cruelty inflicted may be both unwarranted and extreme because technology is employed at a distant location and the bully does not observe the immediate response of the target. Additionally, supervision by parents and teachers is difficult because many adults do not have the technological know-how to track online activity of children in their charge. Cyberbullying comes in various forms, including cyberstalking, denigration (using gossip and rumors), exclusion from groups, false identity (hacking an account), phishing (obtaining personal information using pretend site), flaming (posting photos, images, or graphics), masquerading (using a false identity), sexting (posting sexually suggestive photos), trickery (convincing victim to reveal secrets), outing (humiliating victim by disclosing private information), and grooming (predator builds online relationship with a child for exploitation). Victims of these deceptive practices are often youth without a secure, fully developed sense of self, and so the psychological harm can feel overwhelming. Once targeted, victims tend to feel depressed, angry, and frustrated. Studies have established links between cyberbullying and low self-esteem, family problems, academic difficulties, school violence, delinquent behaviors, and suicidal ideation (Notar et al. 2013; Hinduja and Patchin 2014). In a study at four universities, both students and faculty reported suicidal ideation when targeted by cyberbullies (Cassidy et al. 2017). For both victims and offenders, suicidal ideation and suicide attempts are more probable than for those not involved with this form of peer aggression. Victims of cyberbullying are more strongly linked to suicidal behaviors than offenders (Hinduja and Patchin 2010).

Workplace Bullying In addition to the real possibility that effects of childhood bullying continue into adulthood, there is increased reporting of bullying during adulthood. In fact, there is some correlation between an adult bully and being victimized by bullying as a child (Zuckerman 2016). The majority of adult bullying takes place in the workplace, with an estimate of one in three employees in the United States experience bullying at their place of work. Findings indicate that workplace bullying results in depression, anxiety, and other mental health problems (Zuckerman 2016). In a longitudinal study completed in Norway, an association was found between workplace bullying and suicidal ideation (Nielsen et al. 2015). The study revealed that workers being bullied who felt that they were in an inescapable situation with no means of stopping the bullying were most at risk. A more recent research study

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confirms an association between workplace bullying and suicidal behaviors, particularly when physical aggression is used as the means of bullying (Leach and Butterworth 2017). It should be noted that workplace bullying is vastly underreported, as employees fear being bullied themselves, as well as the fear of losing their jobs if they report. Thus, targets of workplace bullying cannot reliably count on coworkers for support, and perpetrators may serially bully others.

Sexual Abuse and Suicidality Child Sex Abuse It was Freud, in The Etiology of Hysteria (1896), who introduced the topic of childhood sexual abuse. He explained hysteria as resulting from sexual abuse perpetrated on his patients by parents, older siblings, or other family relations. His hypothesis that it is the repressed memories of early abuse that manifest in hysterical and neurotic symptoms marks the genesis of psychoanalysis. What led to Freud’s later revision that these repressed memories were merely childhood fantasies was his disbelief that child sexual abuse could be so prevalent. It has been stated that child sexual abuse is the form of child maltreatment with the most robust association with later suicidal behavior (Bahk et al. 2017; Angelakis et al. 2019). Though physically abused children pose a risk of suicide, being sexually abused puts victims at even greater risk (Lopez-Castroman et al. 2013). In an Australian study of sexually abused youth, it was determined that this group committed suicide at 10.7 to 13 times the national average (Plunkett et al. 2001). Evidence has been found that sexually abused children are significantly more likely to engage in suicidal ideation and suicide attempts than nonabused children (Briere and Runtz 1986). The same study determined that the three strongest correlates with suicidal behavior were multiple perpetrators, sexual penetration, and co-occurring physical abuse. Estimates measure that for each additional act of sexual abuse perpetrated, the probability of a suicidal action increases by a factor of 1.25 (Breiding et al. 2014). Several factors have been found to increase the likelihood of suicide attempts, though not completed suicides: abuse by acquaintance, parental denial, and anger displayed by a parent who blames the child for the act (Plunkett et al. 2001). Though many studies confirm depression as a certain consequence of sex abuse for all youth, youngest children display the greatest intent for suicide attempts (Lopez-Castroman et al. 2013). In sexually abused adolescents, it may be that self-harm and social avoidance are half-way measures designed to escape the situation. All young children are vulnerable and can be taken advantage of by sexual predators, but those who are physically or mentally compromised are the most vulnerable. Females tend to be more vulnerable, as they suffer child sex abuse at twice the rate of males (Bremner 2003). Sexual abuse that co-occurs with family violence tends to increase the potential for suicidal behaviors (Briere and Runtz 1986).

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Sexual abuse may have such strong correlations with suicidal behaviors because of the nature of the violation. To the individual, the violation feels like a forced invasion of one’s physical body, mind, sense of self, dignity, and sense of free will. What makes the violation even worse is when betrayal is involved. When the perpetrator is a person that you have come to respect, depend on, admire or love, it is an ultimate betrayal. According to the Department of Justice, family members sexually abuse children 34% of the time, acquaintances abuse 59% of the time, and strangers just 7% (Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, National Crime Victimization Survey, 2010–2016, 2017).That means that child victims know the sexual assaulter 93% of the time. A metaphor is apt here. The betrayal of trust is taking the knife in the back of the child from the sex abuse and twisting that knife further into the child’s back.

Abuse by Clergy While sexual molestation or rape by a family member represents an ultimate betrayal, molestation or rape committed by a member of the clergy is appalling in its own particular way. Clergy have the command of a congregation of adherents and carry an air of moral authority. Simply put, they are perceived as representing God and communicating holy words to congregants.The “unique betrayal” of sexual abuse by clergy of all religions represents a violation of the child’s body, as well as a violation of a very sacred trust. Roman Catholic priests are regarded as “alter Christus,” another Christ (Guido 2006). Families reinforce the imprimatur of sacredness by willingly entrusting their children to clergy. The term imprimatur is rooted in Roman Catholic scripture. The impact of abuse by clergy tends to linger for many years into adulthood. Religion-related abuse can involve more psychological damage to the child than abuse “not inflicted in the name of God” (Vieth and Singer 2019). The shame experienced by victims breeds silence, depression, helplessness, and the potential for suicidal behaviors (Konopka 2015). Studies show that abuse by clergy damages the child’s relationship with God, causing victims to think that God does not love or value them (Walker et al. 2009).Of course, this would render child survivors less able to use God to cope with the abuse, which compounds the risk of suicide. When these cases come to light years later, victims are forced to relive painful memories and trauma, exacerbating the potential for suicidal behaviors.

Neurobiological Impact of Child Sex Abuse It is well documented that child abuse does both immediate and long-lasting damage to the brain’s functioning, cognitional abilities, and emotional regulation. Specifically, abuse results in significant impairments to the stress response, which involves the prefrontal cortex, the amygdala, and the hippocampus (Bremner 2003). Abuse and trauma cause the amygdala to become hypersensitive and the hippocampus to

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lose capacity to inhibit fight-or-flight responses. The result is an individual living with constant anxiety and overreactive to any stress. Child sexual abuse disrupts normal responses to stimuli, aversive, or pleasant (Konopka 2015). Neurobiological impairments result in both diminished cognition and emotional dysregulation, which play roles in subsequent development of child and adult psychopathology. These impairments, along with dysfunctional responses to stress, make plausible the statement that sex abuse is the leading cause of PTSD in females (Bremner 2003). Cognitive impairments and emotional dysregulation have been independently associated with suicidal behavior. Additionally, there exists evidence that child abuse alters the chemistry of the brain, particularly serotonergic neurotransmission, which mediates depressive states (Turecki 2014). Associations between depressive states and subsequent suicidal behaviors are well documented (Bremner 2003; Castroman 2013; Turecki 2014; Konopka 2015).

Adult Rape and Sexual Assault As far back as the Greek and Roman Empires, rape has been considered a heinous crime worthy of harsh punishment. However, it was typical for the rapist, as well as the girl or woman victim to be punished. In Medieval Europe, it was common for the rapist to pay a monetary fine to the father or husband of the victim or be required to marry the victim. In present times, few rape cases are actually prosecuted and victims are still silenced with monetary pay-offs. It is understandable that feminists and others have proclaimed the existence of a rape culture in society (first articulated by Susan Brownmiller as “rape-supported culture” in Brownmiller 1975). Rape culture may be defined as an environment where rape and sexual assault of women is normalized and perpetuated in language usage, popular culture, and the media. The odds are stacked against female victims who contemplate reporting the crime. Those who do attempt to report are faced with intrusiveness into the details of the rape and their personhood, which can feel like a secondary rape (Campbell 2008). Again, silence and shame may lead to depression, and unchecked depression can result in suicide. Perpetrators of sexual crimes are less likely to go to prison than perpetrators of all other crimes. According to the Department of Justice’s National Crime Victimization Survey ( 2017), of every 1000 sexual assaults, 230 cases are reported to police, 46 lead to arrest, 9 get referred to prosecutors, 5 lead to a felony conviction, and 4.6 are incarcerated. Basically, 995 out of 1000 sexual assaulters walk free. In the United States, approximately 19.3% of women and 1.7% of men have endured rape during their lifetimes (Breiding et al. 2014). The same study revealed that in intimate partner relationships, the rate of rape of women was 8.8% and 0.5% for men. These depressing statistics are mirrored in the depressing states of mind of victims, both female and male victims. A cross-sectional study of the British population showed that for both women and men, there exists a definite association between being sexually assaulted and suicidal behaviors (Cassels 2009). The research reveals that, for women, sexual assault is an

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actual precursor of suicidal behavior. When contemplating the prevalence of rape, the severe multilevel violations involved, the tendency for repeated violations by investigating authorities, the long-term effects of these violations, and the relative lack of justice achieved for victims, the scenario for suicidal behaviors is quite plausible.

Sex Trafficking and Suicidality Currently, human trafficking is a global big business that traps many thousands of children and young adults into forced labor and forced sex. Trafficking of youth is considered a severe form of child abuse. The various types of trafficking include gang controlled, pimp controlled, familial trafficking, survival sex, forced marriage, false marriage proposal, or being sold into the sex trade by family, husbands, or boyfriends. Perpetrators use several methods to lure, manipulate, or force their victims into a life of exploitation, such as promises of money, a big contract, a better life, or the use of drugs, paying off debts, threats to harm family members, confinement, starvation, kidnapping, rape, gang rape, and physical beatings. There are typically five stages that predators use to turn out victims: (1) hunting for vulnerable youth, (2) seducing prey into the trap, (3) grooming for “work,” (4) fostering dependency, and (5) seasoning to make the work their new lifestyle. For the most part, the root causes of trafficking are associated with interpersonal violence. Family disruption and prior victimization are considered precursors to being trafficked (Frey et al. 2019). In general, vulnerable children and adolescents are trafficked after suffering from physical abuse, neglect, sexual molestation, rape, or were runaways, throwaways, or incarcerated as juveniles (Fedina et al. 2016). Environmental factors include poverty, homelessness, or having family members or neighbors involved in the sex trade. Once these cases come to the attention of the criminal justice system, victims are frequently harmed upon initial arrest, as the prostitution laws of many states tend to criminalize sex trafficked minor victims (Songs 2017). When age is ignored and victim status is denied, criminalized victims are confined by the justice system and endure further abuse and trauma. Once freed, sex trafficking victims face tremendous difficulties in overcoming what is often years of complex forms of abuse. Children and adolescents who are sexually exploited are at high risk for health conditions such as drug addiction, pregnancy, sexually transmitted diseases, acute infections, broken bones, vaginal and anal tearing, and traumatic brain injuries. Characteristic mental disorders include substance abuse, anxiety, depression, posttraumatic stress, and suicidality (Barnert et al. 2017). Studies have established direct associations between commercially sex trafficked victims and major depression, PTSD, and suicide (Greenbaum and Crawford-Jakubiak 2015; Frey et al. 2019). In a survey of male and female sex and labor-trafficked victims in the Far East, it was determined that 12% of victims either tried to harm themselves or attempted suicide (Zweynert 2015). It has been estimated that the number of sex-trafficked children in the United States is in the hundreds of thousands, with approximately 14,000 trafficked into the

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country every year (Finklea et al. 2015). Increasingly, there is greater awareness of this public health problem, but governmental and private agencies are overwhelmed trying to identify victims and provide services. Considering the national and international scope of sex and labor trafficking, the multiple and severe abuses involved, the long-term harm to families of victims, and the life-long impact on the victim, the depth and breadth of this predatory violence is enormous.

Domestic Homicide, Suicide, and Firearms The Centers for Disease Control reported that during 2015–2016, there were a total of 27,394 firearms homicides and 44,955 firearm suicides among the US residents. Of the total number of homicides, 74% were the result of injury by firearm (Kegler et al. 2018). The suicide deaths resulting from firearms accounted for 50% of the total. Research shows that having a firearm in the home is a definite risk factor for suicide, but there was an inverse association for suicide by other means (Wiebe 2003). Regarding homicide, a recent study revealed the strong association between gun ownership and domestic homicide, as opposed to nondomestic homicide (Kivisto et al. 2019). In homes with intimate partner violence, the use of firearms has a higher base fatality rate than the use of other weapons (Sorenson and Wiebe 2004). Overall, both gun ownership and gun possession in the home are risk factors with regard to firearm homicide and firearm suicide. The use of firearms is distinctly prioritized (weapon of choice) in domestic violence homicides, bullying murders, and murder-suicides (van Wormer 2008). Every month, in the United States, approximately 52 women are shot and killed by their intimate partners. A review of 22 empirical research studies in England and Wales showed that while perpetrators of spousal homicide primarily used a sharp implement, perpetrators in the United States most frequently used a firearm (Aldridge and Browne 2003). In homes with guns, a study showed that almost two-thirds of the time domestic violence offenders used them to threaten, scare, or harm the victim (Sorenson and Wiebe 2004). The same study indicated that 6.7% of women reported that they used a gun to threaten, scare, or intimidate their partner, or to defend against him. Another review of studies revealed that for at least 90% of perpetrators of domestic murder-suicide in the United States, the weapon of choice was a firearm (Eliason 2009). A 3-year study of murder-suicides in 17 states showed that for both male and female offenders, the primary weapon used in 88.9% of cases was a firearm, 3.9% involved a sharp instrument, 2.5% were with poison, and 1.4% involved suffocation or hanging (Logan et al. 2008). The data on filicide shows that when younger children are murdered, personal weapons (e.g.: hands, feet) are typically used (Logan et al. 2013). When older children are murdered by family members, the most frequent weapons are firearms or knives. Studies have shown that the interval between consideration of suicide and the actual attempt is usually 10 min or less (Deisenhammer et al. 2009; WolfordClevinger et al. 2017). Individuals experiencing suicidal ideation tend not to

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substitute a different method when firearms are not presently available. Though interpersonal murders by firearms may be premeditated, acts of impulsivity and accessibility of guns are factors that increase the number of domestic homicides. It is important to consider that firearms are more frequently found in homes where domestic violence incidents have been reported than homes without domestic violence (Sorenson and Wiebe 2004). The rate of firearms deaths in the United States reached its highest levels in 50 years in 2017, when 14,542 died from homicides and 23,854 died by suicide. The total number of deaths by firearms was 39,773 for the year. It is obvious that in addition to prevention and intervention efforts to reduce all forms of interpersonal violence and suicide, the prevalence of guns in our society must be addressed.

Suicidality and Interpersonal Violence – Future Directions Multimorbidity The very title of this chapter exemplifies a serious comorbidity. Interpersonal violence is a broad term encompassing domestic violence, child abuse, sexual abuse, bullying behaviors, and various familial homicides. When performing a clinical assessment of a patient, two of the most important items to evaluate in terms of severity are suicidality and homicidality (Basu et al. 2018). Delivery of services to individuals exhibiting severe forms of abuse or violence mandates the consideration of multimorbidity, both presently and with past history. It is invariable that by the time an individual displaying these behaviors comes to the attention of authorities and professionals, there have been multiple prior incidents of violence or suicidal behaviors. Additional likely morbidities include substance abuse, mental illness, physical illnesses, and social problems such as divorce, unemployment, infidelity, eviction, and parenting issues. Until there is effective treatment and rehabilitation, crises of various sorts may be ever-present. There is much complexity to manage in these cases, beyond the presenting problem.

Coordinated Assessments The screening and assessment of suicidal patients and individuals involved in interpersonal violence must be bi-directional. Those at risk for suicide must be assessed for family violence, and both victims and perpetrators need to be evaluated for suicidal behaviors. For the most part, first responders, police, EMT’s, shelter workers, the legal system, social services, and clinicians have focused on the victims of family violence and abuse. Perpetrators, particularly domestic offenders and bullies, also need to be assessed for suicidality. It is important to note that victims who are removed from abusive situations are still at risk for suicide. Of course, the strongest predictor of suicidality is the past suicidal behavior.

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Additionally, screening is needed for multimorbidity, such as the typical correlates of suicides and homicides. The most immediate primary triggers include substance abuse, mental health disorders, and recent separations and divorces. The tendency of law enforcement personnel, social workers, and mental health providers, adhering to their areas of specialization, to focus on a single issue rather than a more holistic approach in keeping with the multifaceted human beings they service, must be overcome. Correspondingly, individual agencies tend to work in silo-like diligence. Thus, multi-interagency communications are essential in the campaign to prevent suicides, domestic homicides, and murder-suicides.

Intervention and Assessment of At-Risk Youth The primary precipitating factor for suicidality in young children is interpersonal problems, often related to abuse or violence in the family. As children develop into early adolescence, bullying can become a precipitant as well. In studies of the strong association between child maltreatment and suicidal behaviors, both in children and in adulthood, Angelakis et al. (2019) recommended a community-based approach so that youth have access to multiple areas of support. When youth present with suicidal behaviors, assessments must also evaluate child maltreatment and family violence. The converse is apt, as those referred for abuse in the family need to be evaluated for suicidality. Information gathered must be detailed, so that it can serve as a useful guide for intervention and treatment plans. When assessing these areas, validity is increased with the use of multiple assessment methods, which include self-report, questionnaires, and interviews with family members, school personnel, and peers. Though children often present with somatic complaints and physical injuries, pediatricians, families, school personnel, and peers need to be educated to recognize a variety of warning signs. During the course of an intake or interview with children, it may be appropriate to ask directly about suicidal thoughts. Early intervention in youth following reported abuse or violence in the home is key to reducing present and lifetime rates of suicide. At-risk youth need particular help to establish strong social support networks, learn problem-solving skills, and acquire techniques to enhance emotional regulation in early developmental stages of childhood. To better help children cope with interpersonal violence in the family, continued research is needed to understand how the Adverse Childhood Experiences model, the Diathesis-Stress model, and other similar paradigms associate with suicidality.

Protective Factors for Bullied Youth Studies have been done that focused on the psychological and social protective factors that help prevent suicidal behaviors among youth victims of bullying. The strongest protective factor was found to be parent connectedness, which is

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manifested in feelings that children can freely talk to their parents and that their parents care about their well-being (Espelage and Holt 2013). Additional helpful factors included connections to other adults, caring friends, and fondness for school. Intervention needs to encompass the realities that bullying or recurrence of bullying is more likely with the occurrence of violence in the family and the presence of anxiety and depressive disorders. Conversely, anxiety, depression, and other mental and social disorders are more likely to appear subsequent to being bullied. Both intervention and treatment professionals must screen child victims for potential suicidal behaviors. The impact of bullying is widespread, as the effects are felt by victims, perpetrators, witnesses, family members, and the entire school environment. With regard to cyberbullying, the most important preventative is to educate the school community about responsible Internet use. Creative strategies that reach the students are essential to minimizing its occurrence. Positive messages in the form of art projects can be posted around school campuses, videos and public service announcements conveying messages of respect and kindness can become student assignments, and antibullying messages can be built into the curriculum of the many classes that employ technology. It is important to condemn the behavior of cyberbullies, not the person of the offender, a distinction that helps send the appropriate message to the rest of the school community. In 2012, Lady Gaga, partnering with the Harvard University School of Education, launched the antibullying campaign “Born This Way.” This foundation is based on her own experiences as a bullied child and takes its name from her album and song. The overall theme for Lady Gaga and other antibullying campaigns, such as stopbullying.gov and MTV’s athinline.org, is to promote positive messages for youth centered on self-acceptance and kindness toward others.

Preventative Measures for Child Sexual Abuse Those involved in prevention, intervention, and treatment of child sexual abuse must consider that the vast majority of sexual perpetrators are males, and a similar majority of victims are female. According to studies, one in nine girls under age 18 and 1 in 53 boys under 18 is a victim of sexual assault (Finkelhor et al. 2014). Sexual assault victims, especially children, experience feelings of powerlessness and helplessness that are associated with suicidal behaviors (Briere and Runtz 1986). Once victimized, a stigmatization of the victim often occurs, endures over time, and has long-lasting effects on self-esteem, school performance, ability to form relationships, and development of psychological disorders. Depression and suicidal behaviors frequently arise. The language communicated to victims about their experience must be sensitively worded to avoid stigmatization and self-blame. It is important to be aware of the likelihood that physical abuse co-occurs with sexual abuse. The severity of different types of sexual abuse must be assessed, as more severe sexual abuse (rape, penetration) and more severe physical abuse increase the probability of suicidal behaviors (Castroman et al. 2013). Early onset of sexual abuse and multiple assaults are factors that increase rates of suicidality.

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Further studies are warranted in order to discern the link of specific variables of sexual abuse to suicidality. Information gathered in these studies would bring more knowledge regarding the effects of age of first victimization, presence of intercourse, number of assaults, number of perpetrators, and the occurrence of abuse and violence in the home. The ultimate purpose is to conduct more effective assessments and improve treatment to help reduce self-destructive and suicidal behaviors in sexually abused youth.

Recommendations for Sex Trafficking When child and adolescent victims of sex trafficking come to the attention of police, social workers, pediatricians, and medical health workers, a wide variety of issues are first presented. These workers need to have awareness of variables related to trafficking of youth, such as trauma, physical injury, drug addiction, infection, pregnancy, and mental disorders. Environmental factors such as truancy, child abuse, running away from home, prostitution, and involvement with child services or juvenile justice, are often part of the dynamic. Evaluations must be quite comprehensive and professionals must be prepared to collaborate with professionals in related fields. Assessment and treatment of this vulnerable population must be conducted with sensitivity to the safety and stress level of the victim. Prevention efforts need to encompass education of both families and social service professionals regarding the recruitment techniques of predators, both in-person and via the internet. Lastly, those recruited into the commercial sex exploitation trade must be treated as victims rather than as juvenile offenders.

Prevention of Murder-Suicide Though the infrequency of occurrence of murder-suicide presents an obstacle to gathering reliable data, there exist commonalities in cases that can serve to alert professionals to possible risks. Three rough profiles of perpetrators include: (1) a recently separated or divorced middle-aged male who suffers from depression and has access to firearms, (2) an older male who is the primary caregiver for a sick or debilitated spouse, suffering from depression and having access to guns, and (3) an older male with a newly diagnosed life-threatening illness. Another at-risk group are young mothers presenting with severe depression, who pose a risk for infanticide. Assessments must encompass risk for suicide, homicide, and murder-suicide. Evaluations need to include awareness of special situations involving custody disputes, spouses seeking revenge, and a mother or father’s incapacity to parent. Clinicians must be aware of filicidal potential for all depressed parents. When children become involved in murder-suicides, it connotes the severity of the multiple stressors, hardships, and abuses the family is dealing with. In a proactive manner, services designed to help families need to be promoted and made easy to

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access. There also needs to be coordination among services that work with interpersonal violence, victim services, child protection services, medical care systems, mental health providers, law enforcement, and family and criminal courts. With communication and cooperation across all social service-type agencies, a true safety net can be provided for families in need, and the appalling crime of filicide can be greatly reduced.

Promising Approaches to Suicide Prevention The Suicide Prevention and Resource Center advocates improving the capacity of emergency departments; changing the tone and language of how society and the media talk about suicide, emphasizing hope and connectedness; and reducing access to lethal means and weapons (Reed 2015).The rising rates of suicidality in recent decades in the United States led to the formation of the National Strategy for Suicide Prevention (2012). A key feature of this strategy, the Zero Suicide project, is based on knowledge gained from successful efforts of various health care systems (Reed 2015). Widespread multimedia campaigns have proven to have some effectiveness reducing suicidality. Specific areas that need to be targeted include: comprehensive screenings of all patients, pre-emptive engagement with at-risk individuals, use of evidence-based clinical treatments, teaching conflict resolution skills in primary and secondary schools, and supporting connections to family members, peers, teachers, and various community centers. On a societal level, suicide must no longer be viewed as a taboo subject. The commonality of suicidal ideation must be acknowledged so that at-risk individuals can overcome their secrecy and shame and reach out to numerous lay and professional persons who are all too eager to help.

Further Research Though research in the areas of suicidality and interpersonal violence has been increasing, there are particular matters that merit further study. Specific correlations in need of additional research include specific types of child maltreatment with suicidality; onset and severity of child sexual abuse with suicidal behaviors; early childhood traumas with adult suicidality; bullying victimization with later suicidality or perpetration of violence; sexual abuse of males with suicidality; and association of environmental factors such as infidelity, divorce, unemployment, financial hardship, and substance abuse with murder-suicide. The collateral effects of suicide on other family members would provide valuable information. Research studies of the neurobiological impact of various types of interpersonal violence are presently underway. A recent study linking PTSD with suicidality presages the possibility for further studies to determine if biomarkers exist in the brain that prospectively identify individuals at risk for suicide (Barredo et al. 2019). There exist countless people worldwide who are first responders, intervention specialists, counselors, clinicians, advocates, researchers, and those working to prevent suicide and all forms of

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interpersonal violence. More than gratitude must be extended to these individuals. From their work, inspiration and a shared sense of purpose can be harvested and reaped in order to replace suicide and family violence with peaceful resolution of conflict, appreciation of differences, and recognition of the at times elusive, yet unwavering commonalities that unite us all.

Key Points • Suicide is an increasingly alarming public health crisis in the United States, and has strong correlations with various types of interpersonal violence. • Victims of domestic violence suffer definite psychological consequences, and suicide can seem like the only plausible escape. • Murder-suicides are more often perpetrated by males suffering from depression, with separation and estrangement frequently being immediate precipitants. • For both young children and adolescents, family problems, including abuse and violence, are significant risk factors. • The ACES model of child maltreatment indicates that childhood trauma is an indicator of adult suicidal behaviors. • Bullying can be viewed as an intergenerational problem that manifests in parental abuse, bullying in school, and subsequent adult perpetration. • Cyberbullying can result in severe consequences for victims, can be posted in various forms, and is exacerbated by the relative anonymity afforded to perpetrators. • It has been documented that child sexual abuse is the form of child maltreatment with the strongest correlation with suicidality. • Rape culture is intrinsic to many diverse societies and serves to exacerbate the difficulties that sexual assault victims have reporting rape and achieving justice from the legal system. • Firearms is the weapon of choice for suicides, domestic homicides, and murdersuicides. • Basic essential tasks to help reduce suicidality include research to further specify correlates with interpersonal violence, increase assessment and identification of at-risk individuals, reduce access to firearms, normalize discussions of suicide, and promote the importance of hope and connectedness.

Summary and Conclusions Any writing on the topic of suicide must increase knowledge of suicide (risks, causes, indicators), inspire innovative clinical and societal interventions, stimulate further research, and ultimately reduce the rate of suicidality. The abstract of this chapter began with some alarming data on the current and increasing rate of suicidality. To achieve the ultimate goal of reducing suicidality, it may be helpful to take a polar opposite perspective on the matter. Rather than focus on the number of

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suicide victims, it would be instructive to try to contemplate the difficult-to-determine vast number of people who have given frequent or even very occasional thought to suicide (suicidal ideation) at some point in their lives. A more public sharing of that – somewhat personal – information would help to normalize discussions of suicide, help remove the taboo stigma attached to it, and reveal the societal ubiquity of suicidal ideation. This would facilitate the outing of suicide as an appropriate topic for public discussions, which would naturally increase awareness, both individually and collectively. With this shift in perspective, people can better monitor themselves and keep a caring eye on their neighbor. Various studies are referenced throughout the chapter which attest to the correlations between different forms of interpersonal violence and suicidality, with child sexual abuse having the strongest correlation. Exposure to severe or chronic abuse in any intimate relationship, as revealed by self-report or clinical observation, typically results in affects such as shock, fear, anxiety, depression, betrayal, isolation, and hopelessness. It does not take a distant jump in logic to see the association of these affects to suicidal behaviors. When considering specific types of interpersonal violence, it is important to understand the differences in dynamics of the abuse, the short- and long-term psychological impact on victims, the time frames involved between acts of violence and suicide attempt, and the more difficult to ascertain motive for the suicide. The chapter concludes with several promising ideas to reduce the problem of suicide in the United States. Further studies need to be targeted to preemptively identify at-risk children and adults, improve the coordination of assessments among first responders, law enforcement, hospital workers, clinicians, and social workers, and further clarify correlations between suicidality and various forms and degrees of interpersonal violence. Additionally, there exists a pressing need to reduce access to firearms for both violent and at-risk individuals, normalize the topic of suicide so as to engender increasing public forums on the topic, and place vigorous emphasis on the importance of interconnectedness among individuals and communities, as both an antidote to isolation and a means to share the deep pain for those on a path toward suicide.

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Victor I. Vieth and Pearl S. Berman

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Work of the National Partnership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Scope of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unequal Access and Other Barriers to Systems of Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Improving the Development and Delivery of Prevention Initiatives Within a Coordinated Community Public Health Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Developing a Competent Workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Strengthening Health and Mental Healthcare Responses to Violence . . . . . . . . . . . . . . . . . . . . . . . . . Strengthening Justice System Responses to Cases of Interpersonal Violence . . . . . . . . . . . . . . . . . Connecting Research to Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Improving Public Awareness and Public Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Public Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Provide Public Policy Advocacy Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. V. I. Vieth (*) Education and Research, Zero Abuse Project, St. Paul, MN, USA e-mail: [email protected] P. S. Berman Indiana University of Pennsylvania, Indiana, PA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_299

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Abstract

The National Partnership to End Interpersonal Violence is dedicated to the human right to be safe at home, at school, in the community, and within the institutions of society. There is daily proof across all of these contexts that broad changes are required to make this human right a reality. Research documents that violence can be prevented whether against children (Hostinar and Miller, Am Psychol 24(6):641–652. http://dx.doi.org/10j.1037/amp0000520, 2019), adults (Howell et al., Psychol Violence 8(4):438–447. https://doi.org/10.1037/ vio0000147, 2018; Richards and Gover, Int J Offender Ther Comp Criminol 62(4):851–867. https://doi.org/10.1177/0306624X16663890, 2018), or older adults (Robinette et al., Soc Sci Med (1982) 198:70–76. https://doi.org/ 10.1016/j.socscimed.2017.12.025, 2018; Wilkins et al., Connecting the dots: an overview of the links among multiple forms of violence. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention/ Prevention Institute, Atlanta/Oakland, 2014). However, it requires the recognition of the multifaced causes of violence and the tremendous price tag society is paying for the physical pain, emotional suffering, and loss of productivity that it causes. The following National Plan to End Interpersonal Violence details a public health approach that would transform current educational, judicial, protective service, and treatment systems. These systems would become evidencebased, delivered within a public health model, and would provide equal access to all citizens. Twenty-two recommendations are provided along with strategies for implementation. If fully implemented, this plan would make interpersonal violence a rare event in three generations. Keywords

Education · Evidence-based · Interpersonal violence · Lifespan · Multidisciplinary teams · NPEIV · Polyvictimization · Public health · Public policy · Violence prevention

Introduction The Work of the National Partnership The National Partnership to End Interpersonal Violence Across the Lifespan (NPEIV) is a nonpartisan, group of individuals, organizations, agencies, coalitions, and groups that embrace a national, multidisciplinary, and multicultural commitment to the prevention of all forms of interpersonal violence. We believe it is a basic human right to be safe at home, safe at school, safe in the community, and safe when interacting with the institutions of our society. Additionally, all people should have equal access to effective systems of protection, justice, health, and education. Accordingly, it is our mission to work toward eliminating all forms of interpersonal violence, for all people, in all communities, at all stages of life. To this end, this chapter summarizes a number of recommendations based on research, best practice,

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and common sense which, if fully implemented, would dramatically advance the goal of ending interpersonal violence.

The Scope of the Problem There is a large body of research documenting significant levels of trauma in childhood (Felitti and Anda 2010; Finkelhor et al. 2014), at school (Carlyle and Steinman, 2007; Espelage et al. 2015), in college (Sinozich and Langton 2014), in the military (Gibbs et al. 2007), in intimate partner relationships), and in our elder years (Acierno et al. 2010). Violence at one level often leads to violence at multiple levels (Turner et al. 2010). For example, most trafficked children were originally violated in their own homes. A child or adult abused in one way is often abused in multiple ways, and this pattern of victimization can extend throughout the life cycle (Turner et al. 2010). Violence often has a profound impact on our physical, emotional, and spiritual health (Felitti and Anda 2010; Finkelhor et al. 2014). As a nation, we spend hundreds of billions of dollars dealing with the aftermath of all forms of interpersonal violence and abuse (Fang et al. 2012). It is well documented that exposure to all forms of interpersonal violence and abuse occurs across all socioeconomic levels, and it is considerably more common among impoverished families and communities (Malley-Morrison et al. 2007). Children and adults with a disability (Espelage et al. 2015), or those who are GLBTQ (Kosciw et al. 2013), are also at higher risk of violence. Thus, it is essential that in every section of this National Plan, consideration must be given to the implications of culture in aspects of services delivery, professional development, research, and policy formulation. This National Plan recognizes the challenge of conducting prevention and intervention programs and services to diverse racial and ethnic communities and linguistic groups, each with its own distinct cultural beliefs, traits, and historical challenges. It is for this reason we include cultural tailoring to this National Plan to encourage appropriate interventions for all racial, ethnic, and cultural groups. It is essential to understand that culture is not static nor a “magic” ingredient to be added to the tool box during training or clinical practice and culture involves more than acknowledgment of a specific ethnic group (for a complete list of references, go to www. npeiv.org to see the uncondensed version of the National Plan).

Unequal Access and Other Barriers to Systems of Protection To address the needs of victims of interpersonal violence, it is integral that we recognize the underlying belief systems, values, and attitudes of oppression that impact our understanding, recognition, prevention, and intervention responses. For example, many of those experiencing violence are the marginalized populations within each community lacking access to systems of justice, health, social services, education, and other institutional protections. Adequately responding to these barriers must be a part of developing a holistic, trauma-informed, and systemic approach to addressing interpersonal violence:

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(a) Through a focus on collaborations with criminal justice, medical, public health, social services, mental health, education, community, and faith-based organizations and allies, we must bridge gaps to improve current systems of care on local, regional, and national levels. (b) Our goal must be to build, expand, and sustain organizational and community capacity to make trauma-informed, culturally relevant services available to all people.

Improving the Development and Delivery of Prevention Initiatives Within a Coordinated Community Public Health Model Violence is a significant public health issue and needs to be addressed as such. In developing prevention strategies, it is critical to expand prevention within and across all communities with an emphasis not just on taking actions but also on changing social norms that promote, or at least permit the use of, violence. This includes a deeper appreciation of intergenerational and vicarious trauma. There are many factors that contribute to child maltreatment, domestic violence, human trafficking, sexual assault, elder abuse, cruelty to animals, or other forms of interpersonal violence (Hamby and Grych 2014; National Link Coalition 2012). Individuals engaging in substance abuse or who themselves had poor parental role models are at greater risk to offend against their children. Parental age, stress levels, unemployment, poverty, and child characteristics such as disabilities are additional factors that increase the chances of child maltreatment. Ethnic minorities and immigrants are more likely to live in poorer neighborhoods, have fewer financial resources, and face higher rates of unemployment and higher rates of oppression by the dominant society’s social institutions; these factors may relate to child maltreatment and other forms of interpersonal violence and abuse. Cruelty to animals has been recognized as a potential indicator and/or predictor of child maltreatment, domestic violence, and elder abuse, as part of a pattern of polyvictimization and victim intimidation. Since 1993, cruelty to animals has been listed as a criterion for conduct disorder in successive editions of the Diagnostic and Statistical Manual of Mental Disorders. Higher incidence of animal abuse co-occurs in families under investigation for child abuse and among children who have been sexually abused. Significant research has documented relationships between histories of childhood acts of perpetrating or witnessing animal cruelty and patterns of chronic adolescent and adult interpersonal aggression (National Link Coalition 2012). Given the numerous factors that contribute to child maltreatment, domestic violence, sexual violence, human trafficking, animal cruelty, elder abuse, neglect, and exploitation, and the different levels of these factors in each community in this country, we can never launch effective prevention programs unless these programs are designed at the local level by those closest to the situation and unless these programs are tailored to the dynamics unique to each community. Deborah Daro and Anne Cohn Donnelly evaluated the history of prevention efforts in America and found six factors contributing to the shortcomings of these efforts (Daro and Donelly

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2002). When the shortcomings of past prevention efforts are compared to the overall structure of the National Plan to End Interpersonal Violence Across the Lifespan, there is reason to believe this approach will be more successful. First, Daro and Donnelly accuse prevention proponents of “oversimplifying things” and promoting “singular solutions” (Daro and Donelly 2002, p. 737). Prevention as envisioned by the NPEIV plan will be just the opposite. Recognizing that prevention is complex and will differ from community to community, this proposal puts the responsibility of prevention in the hands of local professionals working with families or others in a given community. Second, Daro and Donnelly accuse prevention proponents of overstating the potential of prevention efforts, allowing rhetoric to outpace empirical research (Daro and Donelly 2002). According to these authors, prevention efforts are usually framed as having the potential for success in all cases, which is an impossible standard to achieve (Daro and Donelly 2002). The NPEIV plan realizes that prevention will not succeed in all cases and, as such, advocates for competent investigators and comprehensive, experiential training programs that will assist in the prosecution of those who commit acts of violence and in working more sensitively with victims of crime through myriad means including speedier resolutions of criminal justice cases. The third and fourth factors are related. Daro and Donnelly allege that prevention advocates “continue to misrepresent the pool of families they can successfully attract and retain in voluntary prevention services” and that these advocates have “failed to establish a significant partnership with their local” child protection or other professionals (Daro and Donelly 2002, p. 738). In cases in which families are unable or unwilling to access preventative programs, the NPEIV plan recommends training, beginning in college, to a wide variety of professionals on the art and science of building prevention programs and getting these programs into the hands of those who will most benefit. Fifth, Daro and Donnelly contend that prevention efforts have focused more on breadth than depth and there has been too much emphasis “on increasing the number of program sites before it fully understood what it would take to make these programs sustainable and effective” (Daro and Donelly 2002, p. 738). NPEIV supports the rights of each community to develop a plan that is adapted to their own unique needs. In support of this, communities can take on some or all of the implementation steps in this plan if they are suited to their community. Communities often face limited resources. NPEIV pledges to use its network of pro bono professionals and volunteers to support any community who needs help in finding the best practices for their communities, as well as helping in implementing these practices if needed. Every community wants to know if their programming is truly serving their people. Communities may well know what the markers of successful programming will be for their community. However, if they aren’t clear on how to track outcomes, the NPEIV plan contains a variety of concrete, outcome measures that could be used to support a community in deciding if their programming was working or was in need of change.

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Sixth, Daro and Donnelly contend the “field has failed to establish the public will and the political clout to bring to fruition the policies and programmatic reforms needed to prevent child abuse” (Daro and Donelly 2002, p. 738). The NPEIV plan advocates educational reforms that teach that people are not born to be violent but engage in violent or abusive behavior as a result of a complex set of situational factors that can be prevented. Future community leaders need educational support in recognizing the tools available for ending interpersonal violence and in taking personal responsibility for supporting their community in taking effective action. This responsibility includes supporting the initiatives already ongoing in their communities or organizing their community in such initiatives when needed. When education provides community members with the tools for effectively communicating the needs of victims, perpetrators, and others impacted by interpersonal violence to local, state, and national leaders, the political sector may be more able to respond to the needs of their communities. Within this broader context, we offer additional recommendations that include goals and outcome measures for determining goal attainment. NPEIV recognizes that some of these recommendations, goals, and outcome measures may need to be refined depending on each community’s unique needs. There are many commonalities among the various forms of violence and abuse, and yet the organizations concerned with each have functioned independently of each other rather than joining their considerable talents to achieve a common goal. The NPEIV plan offers such an opportunity. The recommendations are aimed at eliminating violence and abuse, not one specific form of violence. The proposed framework is a starting point. Something has to be done to stop the violence, and it will take the efforts of all of us to accomplish that urgent imperative.

Recommendations Recommendation 1 Federal, state, and local governments should be encouraged to provide funds for the development and implementation of evidence-based prevention efforts encompassing all forms of violence. Evidence-based, locally developed prevention programs should be developed by community groups to be carried out and evaluated within the next 5 years. There needs to be a clear, national shift toward tailoring evidence-based prevention programs to meet the needs of local communities, thus reflecting the unique dynamics of a given community. Every community has organized groups such as church organizations, fraternal orders of police, NAACPs, mothers against drunk drivers, rotary clubs, and humane animal welfare advocates. These groups have a stake in making their local communities safe. Integrating efforts of local groups toward evidence-based prevention programs, supported by relevant professionals, is therefore recommended.

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As noted earlier, myriad factors contribute to violence, and these factors take on different shapes and forms in a given community. Although there are numerous solid prevention recommendations,3 there is not a “one-size-fits-all” prevention program that will work in every community, with every individual, couple, or family. Communities may know what their unique needs are, and these communities should be free to select evidence-based programs tailored to these needs. If communities need help in the identification process, they should be provided with the resources available for helping them do so. Colleges and universities need to be encouraged to consider how offering pro bono services in partnership with their communities in support of identification, implementation, or measurement of outcomes can further their educational goals for students as well as serve the community. Recommendation 2 Communities should be incentivized to establish multidisciplinary teams to develop, maintain, and evaluate violence prevention programs encompassing the best practices for the particular problems faced by their community. Historically, animal cruelty investigators and forensic veterinarians have been excluded from such violence prevention programs due to a lack of awareness of how often they respond to the same perpetrators and victims as their counterparts in human services and law enforcement. Adding veterinary and animal welfare professionals to multidisciplinary teams (MDTs) could address these gaps. Multidisciplinary teams (MDTs) and/or other professional groups should develop at least one prevention project to be carried out and evaluated by researchers at local universities within the next 5 years. Multidisciplinary teams and other groups of professionals in every community in the United States should be provided with the resources they need to actively engage in prevention planning. One suggested resource to provide financial backing would be local, state, or national prevention grants. One suggested outcome that could be tracked is an annual review of cases of violence and abuse to note repeated patterns. Measuring this outcome would help communities identify what evidence-based programs are tailored to ending these patterns. Grant money would be renewed to groups demonstrating that their programming was effective. Given the complexity of violence, and the diversity of our communities, it is incumbent on professionals, those closest to the children, adolescents, adults, and older adults impacted by interpersonal violence and abuse, to periodically step back and analyze what, if any, prevention programs would actually make a difference in their communities. However, professionals often feel overwhelmed with current responsibilities. They need to be asked what concretely would help them have the time to make effective decisions about violence prevention in their community. One possible method of dealing with time pressure is for community agencies to set aside specific days when they will focus on what prevention opportunities would, in the long run, would be helpful. It might be realistic to have one “prevention planning” day or, if need be, two days. During this event, the MDTs would look at typical cases handled in the previous year and ask what, if anything, could have been

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done to prevent abuse. Perhaps the team noticed an increase in teenage pregnancies and observed that many of these young parents were lacking in parenting skills and ended up physically hurting their children. In such a scenario, teenage pregnancy prevention programming or, where pregnancy cannot be averted, public health nurses or parenting classes for young mothers may have made a difference. This could be an open discussion in which MDT members can share their observations over the years and offer thoughts on available programs that may have prevented at least some instances of abuse. From this discussion, the team should select one to two prevention initiatives they would like to implement (as more than two likely becomes too much). Fast change is possible if communities are given the resources to implement new programming within a year. For example, perhaps a community has too few therapeutic resources for working with perpetrators of violence or sexual assault. Either a specific practitioner could be given an incentive to move to the community or the community could sponsor the continuing education or expansion of scope of competence for practitioners already in the community. Changes in MDT actions might not be needed in every community. For some, resources to expand training within their regional police academy might serve them better. Perhaps police should be trained to screen for adverse childhood experiences of victimization and perpetration in all arrests and identify individuals the court might mandate into treatment services as an alternative to time in jail. Cross reporting between animal cruelty investigating agencies and child protective services could help identify families at risk (National Link Coalition 2012). Many communities may have a variety of ongoing prevention initiatives; some may be more effective than others. Measures of outcome are needed to determine program effectiveness. Outcome data that represent concrete examples of success or failure need to be collected for communities to make informed decisions about whether to keep the program operating, change the program, or close the program down. For example, if the program was to aid resiliency in victims of domestic violence, then concrete signs of success could be outcome measures such as a reduction of emergency room visits for any family member, a decrease in police reports, an improvement of grades in children, no DUI or other alcohol-related offenses, continuous employment, a decrease in homicides, etc. Information about effective programming needs to be made easily accessible to communities. For example, across 7 multidisciplinary teams concerned with responding to elder abuse, neglect, and financial exploitation in California, 369 trainings (5,575 individuals) were provided with mandated reporter training. Media events reached over 400,000 individuals that were hosted by these 7 projects. There were 957 assessments or screenings carried out by the team (Twomey et al. 2010). Thus, one type of programming for communities to consider is the provision of mandated reporter trainings. These should include animal control officers, animal cruelty investigators, and veterinarians who are mandated reporters of child abuse and elder abuse in 30 states but who have not received such training to date (National Link Coalition 2016). While some communities might not view mandated reporter trainings as needed, they might borrow the outcome measures used in this research: tracking the number of assessments and screenings carried out by their MDTs.

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Some communities have partnered with universities or community colleges to provide the needed person-power for program evaluation efforts as community agencies are working at capacity dealing with their day-to-day work loads. How these partnerships work, and can be facilitated, needs to be easily accessible to communities so that they can determine if such a partnership with their closest institution of higher learning might be of value to them. Similar to institutions of higher learning, the use of volunteers has the potential to increase effectiveness for many types of community programs such as MDTs. For example, some MDTs have been highly successful in utilizing volunteers to increase their capacity to respond to elder abuse (Twomey et al. 2010). Again, for communities that decide they want to implement such an initiative, the “how to” used in a successful program needs to be readily available with “Information about effective programming needs to be made easily accessible to communities.” The NPEIV, through its vast network of resources, can be a tool in aiding prevention discussions and helping communities locate evidence-based models that may assist in responding to the unique situations they face. NPEIV could help them locate the most appropriate resource for their needs, such as in cases of elder abuse or exploitation, the National Clearinghouse on Abuse in Later Life (NCALL). The NPEIV website can include a directory of these resources to help communities connect with one of the numerous other partners who are part of the NPEIV. Recommendation 3 Research funds specifically earmarked for the development and validation of violence prevention programs should be made available as this encourages researchers to engage in applied, programmatic research that develops pragmatic initiatives to prevent violence. Making successful programming readily available (e.g., “prevention scouts” or some other designated group) would bring viable ideas for violence prevention to be implemented and evaluated within 5 years. One way effective programming ideas could be brought to the community would be for a member of the community to be designated a “prevention scout” whose job is to attend national and state conferences and engage prevention experts for programs and services that can aid in addressing the needs of a particular community. The scout can then take these ideas back to the community for possible implementation. Rapid change could occur if every community had the ability to easily access new ideas on a yearly basis. One mechanism for doing this is to have communities assign one or more team members to be prevention scouts. Those assigned this honor agree to attend at least one national and as many state conferences as possible with the specific task of looking for evidence-based prevention programs that might be a good fit for their communities. Many national organizations such as the American Psychological Association, the National Association of Social Workers, the American Medical Association, the American Bar Association, the American Professional Society on the Abuse of Children, the National Committee for the Prevent of Elder Abuse, the Alliance for Trauma Informed Care, the National Resource

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Center on Domestic Violence, the Battered Women’s Justice Project, the National Sexual Violence Resource Center, the Academy on Violence and Abuse, and the Association for the Treatment of Sexual Abusers have research-informed and/or empirically research-supported resources on their websites that the scout could also examine. Once discovering materials that might suit the needs of their community, the scout shares these ideas with the local team and community to gain their viewpoints. In this way, the community is constantly being invigorated with fresh ideas for taking prevention to a continually higher level. Recommendation 4 There are diverse clearinghouses and online sites available that provide valuable resources for different forms of interpersonal violence across the lifespan, different types of intervention programing, and different types of prevention initiatives. Funding could be sought so that a multidisciplinary organization consisting of professionals with expertise in child abuse, intimate partner violence, sexual assault, elder abuse, interpersonal violence within the military, animal abuse, and so forth could include a directory on their website to connect organizations, agencies, and people across the country to the sources of information that best suits their needs. Funds could also be sought to develop guidelines and a template for how states could develop effective online resource guides including links to searchable, national clearinghouse programs across the country. A number of frontline professionals have expressed an interest in promoting prevention but were unaware of available programs, sometimes even programs that were operating in their communities (Vieth 2013). Some of these professionals have suggested the utility of a resource guide listing all the available programs in their jurisdiction so they could easily refer families in need or advocate for programming in the schools, day cares, churches, and other institutions with which they interact professionally or personally. The creation of online resource databases will allow community stakeholders to search for specific programs that might meet their unique needs. The easy accessibility of online materials is particularly valuable for communities who lack the financial resources to send prevention scouts farther outside their counties. However, state leaders are needed to make this online resource happen. In addition, state organizations, such as prosecutor or police associations, state Child Advocacy Centers (CAC) chapters, or others, could be asked to help develop lists of resources to send into the state for inclusion in the online data set. To truly help communities, the resources listed must be comprehensive, addressing all forms of abuse and perpetration across the lifespan. To this end, by developing this list, states will be able to determine weaknesses in programming or the shortage of programming in various communities. Shortages of particular types of programming are more likely in communities at a distance from a major city. This accessibility barrier could be addressed by expanding state online resources to include successful programming implemented in other locations or states, such as Darkness2Light.

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In this way, the online resource is made a one-stop shop for prevention ideas for a local community to consider. Once developed, links to the online resource guide should be on the website of every CAC, criminal justice, social service, hospital, or other pertinent agencies that respond to interpersonal violence in the community. Simply put, staff members who have highly limited schedules will have prevention ideas available to them after a quick and efficient computer search. Recommendation 5 Implementing successful programming should be a primary goal and focus. For example, within 5 years, there should be seven or more evidence-based prevention programs in every county in the United States with the sum total of these programs addressing violence across the lifespan. This could decrease violence across the lifespan within each state and make community members feel safe in their communities as a real priority. Communities want to fund only effective programming. : Fast change is possible if within 5 years, every county in the United States made the commitment to having at least seven evidence-based violence prevention programs operating. The gold standard for a community would be if, across these seven programs, all forms of violence across the lifespan were addressed. It is the goal of NPEIV to have a national map to help show the country that prevention can work and that there are ways to measure that it is working. One type of outcome that could be indicated on the map would be the number of communities/counties that can list the seven prevention programs they have up and running so that other similar counties can consider implementation of these programs. The national map would also include outcome measures such as data that supports program effectiveness. New business and populations might be more interested in locating to communities with proven effective programming. If policy makers are so inclined, counties meeting this gold standard should be able to post road signs at their borders announcing they are so dedicated to preventing violence that they have met the national standard necessary for being deemed a “prevention county.” It would be breathtaking to drive through every county in the United States and, with the crossing of each border, read a sign proclaiming, “you are entering a prevention county.” Recommendation 6 Implementing more prevention programs through expanding prevention training to more disciplines with the goal of having at least one pilot program per state. Training for education, social service, criminal justice, drug and alcohol, and medical and mental health professionals could be expanded to include prevention skills. These and similar professionals are often closest to individuals, couples, and families at high risk and can direct these families to needed programming and services.

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Although prevention is both an art and science – it begins with education. As called for in this chapter, students from kindergarten through the 12th grade must be taught the skills they need to understand and regulate their feelings, thoughts, and behaviors, develop supportive relationships, and develop adaptive strategies for dealing with conflict. Many such programs have been developed by humane societies to build interpersonal empathy by promoting kindness to animals. Many animal shelters collaborate with youth service agencies to provide therapeutic interventions for at-risk and offending children and adolescents through training shelter dogs that have similar behavioral challenges, using positive reinforcement techniques (Arkow 2010). Young adults progressing through college or graduate school in a career path that will require them to work with individuals, families, or communities exposed to violence need to be ready to perform this work with excellence. At a minimum, they must know how to prevent violence and, when it can’t be prevented from the outset, prevent its re-occurrence. Recommendation 7 Implementing more prevention programs using technology to maximize the impact for lowest possible cost. Prevention should be made practical and personal through the creation of apps and other technology that can aid children, youth, adults, and older adults in asking the right questions and making the best decisions about personal safety and awareness. We live in a media-driven age, and the tech-savvy youth of today will be the techsavvy adults of tomorrow. Prevention programming incorporating social media, apps, and other forms of communication could become accessed and spread much more quickly than traditional, in-person services. Just as the app Yelp helps determine how some individuals select restaurants, an app could help a social service agency determine what type of new programming might be most effective for their adolescent sexual offenders. Just as the app for Fitbit influences an individual’s decisions about exercising and food choices, apps could be developed to guide individuals seeking guidance on what to do if they are stalked. It would be possible, for example, for personal safety programming to be delivered through an app or web-friendly app. For example, National Immigrant Women’s Advocacy Project (NIWAP) is trying to develop an app phone tool that provides information to help improve victim safety and reduce the potential for victimization.

Developing a Competent Workforce The vast majority of victims of violence intersect regularly with numerous professionals including teachers, healthcare professionals, social workers, criminal justice professionals, faith leaders, and others. Unfortunately, many professionals are poorly trained to prevent violence or to respond with excellence when it cannot

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be prevented. Most of us would not go to a doctor, dentist, or barber poorly trained to mend our bones, fix our teeth, or cut our hair. However, we routinely place cases of violence and abuse in the hands of those with virtually no education on how to address or handle such a task until they have had significant on-the-job experience. In addition to undergraduate and graduate reforms, which are discussed below, developing a competent workforce includes vocational training to ensure that staff at all levels and across all disciplines receive ongoing education and training to include culturally and linguistically appropriate service delivery. Recommendation 8 Undergraduate and graduate programs should address violence across the lifespan and provide students with practical skills necessary to be effective in responding to instances of trauma. Professional training programs should be encouraged to include training specific to trauma-informed care and violence prevention. Licensing boards should be encouraged to include violence prevention and trauma-informed care in their licensing and continuing education requirements. There is a large and growing body of research documenting the inadequate undergraduate and graduate training of criminal justice, social work, and medical and mental health professionals to address any aspect of violence (Knox et al. 2014; Vieth 2006). Unless this training is received on the job, many of these professionals go their entire careers lacking the necessary skills to investigate, prosecute, treat, prevent, or otherwise respond to the needs of victims of violence or offenders (Vieth 2013). For example, one recent study found that even experienced professionals in the field are “uninformed or misinformed” about basic literature relevant to their work with victims or offenders. The United States Attorney General’s Task Force on Children Exposed to Violence has recognized the need to improve undergraduate and graduate training, as one example, and has called for a “national initiative to promote professional education and training on the issue of children exposed to violence” (Listenbee et al. 2012). The task force specifically urges academic institutions to “include curricula in all university undergraduate and graduate programs to ensure that every child and family serving professional receives training in multiple evidencebased methods for identifying and screening children for exposure to violence” (Listenbee et al. 2012) including a recognition that human-animal relationships as sentinel markers for potential child maltreatment, domestic violence, or elder abuse and neglect (Hanrahan 2013). NPEIV supports the recommendations of the Attorney General’s Task Force but expands them to address violence and abuse across the lifespan. In addition to child abuse and neglect, we must dramatically improve undergraduate and graduate training for professionals who will be involved in cases of domestic violence, sexual assault, bullying, elder abuse, trafficking of children and adults, and other forms of interpersonal violence. Since not all professionals attend undergraduate or graduate institutions, there also needs to be an emphasis on vocational training.

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Recommendation 9 It is recommended that academic (grade school through graduate school) curricula include violence awareness, violence remediation, and violence prevention components, as well as support services for those students already victimized. Examples would include bullying prevention programs, bystander intervention, and dating violence programs. Whenever possible, training should include experiential, firsthand laboratory models of learning which research has found to be the most effective for practical learning. Shifting to experiential, laboratory training for professionals in the field has been found to be more effective in preparing individuals for real-life challenges in the field. There is a growing body of research supporting, and a growing number of universities incorporating, experiential-based learning models which actively engage students in applying skills and making decisions in response to realistic scenarios that professional may encounter on the job (Wurdinger and Carlson 2010). While research relevant to specific skills needs to be done, there are studies indicating that experiential activities require more active learning and that students view them positively. This is an important type of training needed in the investigation and intervention of abuse and interpersonal violence cases. In one study, professionals responding to cases of violence expressed a strong desire for hands-on training courses such as mock trials, mock crime scene investigations, or mock forensic interviews. As one law enforcement officer noted, “I need trench training.” According to this officer, “trench training” is experiential learning in which the MDT is processing a mock crime scene, testifying in a mock trial, and conducting mock forensic interviews or suspect interrogations. Experiential training of this kind is often used in law enforcement academies and other setting as investigators and other professionals learn defensive tactics, searches, and other skills. The need is to expand this concept to include training in a much broader array of skills in responding to instances of violence. When developing training for professionals working cases of violence, state and national associations should emphasize workshops and programs that provide experiential training. Similarly, the departments or supervisors sending staff to training should emphasize experiential training as the first resort. Recommendation 10 It is important to maintain a quality workforce by addressing vicarious trauma that can follow intervening in cases involving violence or abuse. Many professionals within the police force and social service agencies experience burnout as a result of the vicarious trauma and compassion fatigue in working with cases of violence and abuse. This not only impacts their ability to serve victims at a high level, but it also results in burnout, reduction in efficacy, and leaving the profession entirely. High turnover creates a perpetual pool of poorly trained, inexperienced workers. Accordingly, addressing vicarious trauma must be a high priority

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for the field. Every agency should have an evidence-based plan for addressing vicarious trauma and compassion fatigue. This plan may include mandated vacations, individualized self-care plans, mental health support, spiritual support, and manageable caseloads. Working with violence can lead to psychological and physical problems which in turn can add expensive health and mental healthcare costs for the providers that can be saved if individuals were enabled to take good care of themselves.

Strengthening Health and Mental Healthcare Responses to Violence Recommendation 11 Accreditation standards of healthcare facilities (e.g., JCAHO) should require all employees to undergo specialized training in violence recognition and response, as well as providing trauma-informed care in all patient care departments. It is suggested that within 5 years, each major medical center routinely incorporates screening for cases of violence and abuse, including male victims of sexual and physical violence, and safety of pets and provides access to needed intervention resources. In Connecticut, for example, mandated continuing education for physicians about domestic violence includes training on how patients’ fears for their animals’ welfare serve as a barrier preventing them from leaving abusive situations. Asking about the safety of pets is a One Health strategy to prevent family violence (Arkow 2015). According to the Centers for Disease Control and Prevention (CDC), 82% of adults have annual contact with a medical professional, and almost 93% of children have annual contact with a healthcare professional (Rothwell et al. 2012). All totaled, Americans make 1.2 billion hospital or physician visits every year (Rothwell et al. 2012). There is, then, clear potential for medical professionals to prevent many instances of violence or at least recognize instances of abuse and intervene promptly and with excellence. Unfortunately, the level of training of most nurses, physicians, physician assistants, and other medical and mental health professionals in recognizing and responding to instances of violence is poor, and many hospitals fail to follow up on even clear signs of abuse (Wood et al. 2015). Accordingly, there is an urgent need to dramatically improve the abilities of physicians, nurses, and other medical and mental health professionals in screening for violence across the lifespan and then responding with excellence when trauma is discovered. With respect to the approximately 8% of children and 18% of adults who do not have annual contact with a physician or other healthcare provider, there remains a need to expand healthcare services to underserved populations. If a child or adult cannot access healthcare on a regular basis, even the most skilled medical provider will be unable to assist.

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A number of studies note the particular reluctance of male victims of sexual or other violence to share their experiences with medical or mental health professionals. The fears of many boys and men are made worse when professionals are ignorant or insensitive to the concerns of male survivors. For example, experts on violence have noted a “gender gap in the health care literature” focusing on the examination of men and women who may have been abused (Gallo-Silver et al. 2014). These experts note that medical literature addressing breast cancer, obstetrics, and gynecology point to the importance of slowing down an examination, inviting greater dialogue with a patient, and seeking permission to proceed (Gallo-Silver et al. 2014). These experts argue that although medical internists and urologists “examine men in a manner proximate to a gynecologist’s examination of women. . .no recommendations exist to address the issue of childhood sexual abuse and its potential impact on adult male patients” (Gallo-Silver et al. 2014). The experts make a number of concrete recommendations for more sensitive examination of men who may have been sexually or otherwise violated (Gallo-Silver et al. 2014). Implementing these changes can be as simple as reading an article or attending a workshop and adhering to the recommendations. Simply stated, this improvement in our responses to potential victims can and should happen immediately. More sensitive examinations of men may result in disclosures of abuse or perpetration and enable the medical community to more adequately address the impact of violence with boys and men throughout the United States. Recommendation 12 It is important to strengthen trauma screening of medical and mental health providers, including addressing the spiritual impact of trauma. To accomplish this it is also important to establish partnerships with faith-based organizations to take the lead in the prevention of violence and abuse in their congregations through traumainformed educational initiatives. The American Psychological Association has published two literature reviews documenting that trauma often impacts us spiritually. This same body of literature documents that when therapists and other professionals adequately address the spiritual impact of abuse, patients often do a better job of coping physically and emotionally (Bryant-Davis et al. 2012). To this end, the APA has published two treatises to assist clinicians in helping children and adults address spiritual questions pertaining to trauma. Just as violence results from a complex interplay of factors, effective intervention requires a complex interplay of resources that may be unique to particular individuals/families. A holistic response to trauma could address the medical, mental health, and spiritual needs of those who have endured violence. There are religious institutions spread across the United States in every state and county. If these institutions became involved in trauma-informed violence education, their impact on reducing violence could be significant.

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Strengthening Justice System Responses to Cases of Interpersonal Violence Although there are numerous reforms that have been suggested for strengthening our justice system, there are two simple reforms which, if fully implemented, could dramatically improve the response of law enforcement and courts to instances of violence. Recommendation 13 The collection of corroborating evidence in cases of violence, as a national norm, would increase successful prosecution of cases. It is recommended that the National Institutes of Justice, working with state and national organizations as well as frontline professionals, develop and disseminate standards for police, prosecutors, and judges regarding the specialized considerations for collection of evidence, administration of restraining orders, and timeliness of response in all cases of intimate partner violence, sexual assault, and elder and child abuse. Corroborating evidence about animal abuse should be included. Veterinary forensics has become a recognized specialty practice with the development of sophisticated crime scene investigation in animal cruelty cases. There is a growing body of evidence that the most important factor determining whether a case of violence will result in a beneficial outcome to a victim is the collection of corroborating evidence. For example, corroborating evidence doubles the chance a suspect will confess (Walsh et al. 2010) in a case of child abuse and plays a significant role in whether a case of adult sexual assault or elder abuse will result in charges (Myers 2011). Despite the clear correlation between corroborating evidence and case outcomes, one survey of criminal justice professionals found that crime scene photographs and other easily obtainable corroborating evidence are collected in less than half the cases (Vieth 2013). The National Child Protection Training Center urges the taking of crime scene photographs in every case where the scene is still available and collecting a minimum of five pieces of corroborating evidence in every case of interpersonal violence or abuse, including animal abuse/neglect (Vieth 2013). We concur in this recommendation and urge this as a realistic goal. Recommendation 14 Training criminal justice professionals to recognize and screen for polyvictimization would help end the cycle of violence for more perpetrators and victims. When a child or adult is abused in one way, they are often abused in multiple ways (Turner et al. 2010). This research, known as “polyvictimization,” often translates into poor medical and mental health outcomes. Accordingly, when law enforcement or other professionals are responding to a case of child abuse, they

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should also consider domestic violence, sexual assault, trafficking, elder abuse, animal abuse, and other forms of violence, and vice versa, that may be present in a family. Similarly, animal control officers and humane investigators should consider whether interpersonal violence is occurring. As of Jan. 1, 2016, the FBI added four types of animal cruelty to its National Incident-Based Reporting System utilized by thousands of law enforcement agencies which will provide much-needed data correlating the co-occurrence of animal abuse with other crimes. Recommendation 15 Holding trials within 6 months of charging for a crime could reduce adverse impacts of violence on victims and family members. The National District Attorneys Association has noted that significant delays in a case coming to trial adversely impacts victims. This includes ongoing stress, family and other pressures to recant, and the loss of memory and evidence. The American Bar Association proposes that nearly all felony cases of child abuse should be resolved within 180 days of arrest (Walsh et al. 2008). We support these recommendations and believe it should extend to all cases of violence including adult sexual assault, domestic violence, and elder abuse. Recommendation 16 The impact and utility of restorative justice initiatives should be studied and then implemented if they are found to be effective in preventing recidivism of perpetrators and emotional healing of victims. Restorative justice is a problem-solving approach to crime, which involves the parties themselves, and the community generally, in an active relationship with statutory agencies (Marshall, 1999). Restorative justice is a fast-growing state, national, and international social movement that seeks to bring together people to address the harm caused by crime. The restorative justice movement has attracted many segments of society, including police officers, judges, school teachers, politicians, juvenile justice agencies, and victim support groups. However, restorative justice remains a controversial concept in the field. This approach focuses on the needs of the victims and the offenders, as well as the involved community, instead of satisfying abstract legal principles or punishing the offender. Victims take an active role in the process, while offenders are encouraged to take responsibility for their actions “to repair the harm they’ve done—by apologizing, returning stolen money, or community service (Webber 2009).” Restorative justice that fosters dialogue between victim and offender shows the highest rates of victim satisfaction and offender accountability. There is a national debate on whether or not there may be alternatives to the criminal justice system in cases of violence. NPEIV encourages this debate and a consideration of a restorative justice approach in some, keeping mind the acts are still criminal. This approach focuses on the needs of the victims and the offenders, as well as the involved community, instead of satisfying abstract legal principles or

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punishing the offender. Victims take an active role in the process, while offenders are encouraged to take responsibility for their actions, “to repair the harm they’ve done—by apologizing, returning stolen money, or community service.” Restorative justice that fosters dialogue between victim and offender shows the highest rates of victim satisfaction and offender accountability.

Connecting Research to Practice Ending violence is achievable, yet many of the recommendations this plan recommends require resources communities often can’t afford. NPEIV makes a commitment to facilitate connections between researchers and practitioners to aid implementation of empirically supported practices. To this end, we would recommend the following: Recommendation 17 It is suggested that we expand the research paradigm to make connections to human rights, social norms, oppression, differential distribution, and prevalence of violence to research, policy, and practice. It is recommended that all federal agencies whose mandates include any forms of violence earmark some percentage of their funds each year to supporting research, conferences, and trainings related to adverse childhood experiences, interpersonal violence and abuse, and the traumatic effects they produce. Aiding professionals in applying research to practice by shortening the time it takes for research findings to be translated into frontline application is needed. On an annual basis, there should be a survey of a minimum of 1,000 professionals from multiple disciplines to determine their awareness of evidence-based practices for addressing interpersonal violence across the lifespan, the best means for communicating this evidence to practitioners, and the issues these practitioners are facing that need research. This latter analysis will aid researchers in determining the most relevant needs of the field. The findings of this survey will be published on an annual basis. This would encourage translation from research to evidence-based strategies with improved implementation. Translating current research for practitioners and defining additional research needs are both important. Frontline professionals often lack the time to read large volumes of research and thus may not remain current in new developments in their field. To aid these professionals, there is a need for more literature reviews of large bodies of research on a particular topic. There is also a need for smaller articles listing best practices or approaches and citing pertinent studies where a frontline professional can learn more. Researchers and other scholars also need to prioritize writing for journals or other forums that can be accessed free or at low cost by large numbers of frontline professionals. To this end, NPEIV will commit to publish the Violence Research Digest and bi-monthly newsletters all freely downloadable to any interested party from the partnership website.

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Improving Public Awareness and Public Policy There are studies indicating public awareness campaigns can have an impact in reducing domestic violence or other forms of violence. The problem, of course, is in determining what sort of educational campaign may work in a particular setting in addressing a particular form of violence. To further the goal of assisting communities in developing evidence-based public awareness campaigns, we have the following recommendations: Recommendation 18 Developing strategic media partnerships could facilitate nationwide campaigns. NPEIV will strive to identify strategic partnerships with major media, advertising, and information companies who can assist in the creation of national public awareness campaigns through social media, viral marketing, and more traditional forms of advertising and outreach.

Public Policy Developing effective public policies is a complicated yet critical aspect for the prevention of violence and trauma. Public policy is often defined as the action taken by governments (local, state, federal, and international) to address a particular public concern; therefore, these actions should be informed by evidence (e.g., research) and practice involving experts in a given area. Evidence should not be narrowly defined to reflect a single model (e.g., medical model) and should address all aspects of an issue in a comprehensive manner. As communities continue to work on ending violence across the lifespan, it would be valuable to have a process that helps guide their understanding of the implications of a given public policy. Development of public policies requires critical decisionmaking to insure generalizability to the broader population that may be impacted by the public policy. The intent of the public policy is to protect and benefit the designated population and to avoid unintended consequences and negative outcomes. For example, current policies designed to protect the community from individuals convicted of sexual crimes unintentionally make them vulnerable to housing and employment discrimination, factors which result in destabilization that has the potential unintended consequence of increasing, rather than decreasing, community safety. A lack of employment or opportunities for employment results in financial instability and an inability for these individuals to meet their own basic needs for food and shelter. The current policies of registration, residency restrictions, and similar policies also result in social isolation which undercuts an individual’s ability for rehabilitation, all factors which actually increase the likelihood of re-perpetration (Tabachnick and Klein 2011). Within these critical parameters, we offer the following recommendations:

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Recommendation 19 Media coverage of candidates for public office should be encouraged to include their positions on issues of interpersonal violence, including (when appropriate) the candidates’ response to this National Plan, and to publicize the answers to the public. Asking candidates their positions on violence and their specific recommendations is important. In order to maximize their impact, organizations must be willing to work with all political parties in addressing interpersonal violence across the lifespan. Recommendation 20 It is important to develop partnerships with grassroots organizations of survivors of abuse and violence such that these groups provide input and play a significant role in the efforts to end interpersonal violence and abuse across the lifespan. In shaping public policy, the voices of survivors have often been excluded in certain types of interpersonal violence and abuse (e.g., adult survivors of childhood abuse) while being quite influential in others (e.g., intimate partner violence). Not including survivors, researchers, and practitioners in policy decisions is a flawed approach which excludes those who may best know what policies and programs are the most effective in helping those experiencing violence and abuse. Accordingly, organizations, researchers, and frontline practitioners working in this field must work together with survivors in developing policy and communicate this critical importance to policy makers as well.

Provide Public Policy Advocacy Training Recommendation 21 Universities instructing future professionals working with victims or perpetrators in any setting should be encouraged to include instruction on public policy advocacy. Public policy advocacy instruction should occur in university courses as well as online such that written materials are available to communities who otherwise cannot access them. As reflected at the outset, effective public policy is a process that involves appropriate experts, stakeholders, researchers, and practitioners. We believe the undergraduate and graduate reforms proposed in this plan should include public policy making instruction as part of these courses. In this way, we will be teaching the child protection, domestic violence, sexual violence, educators, law enforcement, trafficking, animal abuse, and elder abuse experts of tomorrow the basic tenets of public policy making which they can carry out long into the future. To this end, the NPEIV public policy team and other organizations can be a resource to these universities in developing materials or otherwise assisting in shaping this course content. In addition, there must be continuing education for all professionals dealing with cases of violence in the basic tenants of public policy making.

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Many law enforcement officers, social workers, victim advocates, medical and mental health providers, victims, and survivors fail to understand the tremendous power they have to enact needed public policy reforms. Accordingly, NPEIV and other organizations should take a leadership role in providing instruction at national and state conferences as to the art and science of effective public policy advocacy in addressing violence. These workshops and materials should also be offered in an online format for professionals and communities who cannot otherwise access this information. Recommendation 22 End all forms of sanctioned violence within institutions, such as corporal punishment in schools. There is a large and growing body of research documenting that corporal punishment is not an effective form of discipline (Gershoff 2008), with numerous medical and mental health bodies discouraging the practice. For example, the American Academy of Pediatrics contends that the negative consequences of corporal punishment outweigh any benefits and urges parents to find “methods other than spanking in response to undesired behavior” (American Academy of Pediatrics’ Committee on Psychosocial Aspects of Child and Family Health 1998). According to one literature review on corporal punishment research, “[A]t its worst, corporal punishment may have negative effects on children and at its best has no effects, positive or otherwise” (Gershoff 2008). Despite research and the discouraging of corporal punishment by respected medical and mental health organizations, most Americans continue to practice corporal punishment, and many schools permit hitting children as a means of discipline. Histories of corporal punishment have been linked to higher rates of physical animal abuse. Although most states have banned school corporal punishment, 19 states continue to allow educators to physically strike students with instruments. According to the US Department of Education Office of Civil Rights, approximately 200,000 children are physically struck annually in American schools, with African American students and students with disabilities receiving disproportionately high rates. We believe that schools should develop disciplinary policies supported by research and common sense. To the extent educators are willing to do this, state or federal policy makers should act to repeal laws allowing educators to hit children.

Key Points • Violence across the lifespan can be prevented. • Inequality of access to education, medical care, systems of protection, and institutional betrayal fuel violence. • Evidence-based practice is needed to reduce risks and increase resilience to violence.

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• Multidisciplinary teams need to take on a lifespan perspective to assessing violence. • Public health approach needed to end underlying causes of violence.

Conclusions The National Plan outlined here has the potential to dramatically improve our response to violence and abuse in every community. However, even if fully implemented, this plan is only the beginning. Within these broad parameters, there is a need to determine what undergraduate and graduate reforms, prevention, or research may look like for various forms of interpersonal violence and abuse. However, this plan does provide guidance, solutions, and a direction toward the movement to end all interpersonal violence and abuse. It should be recognized that violence cuts across all ethnic, racial, cultural, and gender lines and that all of these recommendations should be considered to be gender neutral. We have waited long enough. Policy makers, legislators, and community advocates need to immediately consider channeling funds into an action plan that addresses as many of the recommendations in this report as financially feasible. The people should encourage the federal government to invest funds aimed at eliminating violence in our own country and communities as well as overseas. This would be a more humane and costeffective effort than responding to interpersonal violence after it has occurred.

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Section II Maltreatment and Victimization of Children and Adolescents Ernestine Briggs, Theodore P. Cross, Amy Russell, Michelle Clayton, Javonda Williams, Stacie Schrieffer LeBlanc, Heather J. Risser, Viola Vaughan-Eden, and Victor I. Vieth

An Introduction to Child and Youth Maltreatment: Consequences and Considerations

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Historical Review of Child Abuse and Child Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Maltreatment and Victimization of Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Physical Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sexual Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emotional Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Family Violence and Teen Dating Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cultural Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Consequences and Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recognizing and Responding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. V. Vaughan-Eden (*) Ethelyn R. Strong School of Social Work, Norfolk State University, Norfolk, VA, USA V. I. Vieth Education and Research, Zero Abuse Project, St. Paul, MN, USA e-mail: [email protected] S. Capuano Morrison IVAT – Institute on Violence, Abuse and Trauma, San Diego, MN, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_335

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Abstract

This National Partnership to End Interpersonal Violence Across the Lifespan (NPEIV) Handbook part on maltreatment and victimization of children and adolescents consists of 65 chapters across the continuum of abuses they experience. This chapter serves as an introduction to the part, which discusses the multidimensional aspects of maltreatment including an overview that defines and analyzes child and adolescent maltreatment through a public health and social justice framework. Throughout this part of the Handbook, recommendations are provided on how to strengthen prevention and intervention efforts as well as how to improve the response of child protection professionals using a traumainformed lens and methods based on the adverse childhood experiences (ACEs) research. The pervasiveness of these forms of abuse as well as the short- and longterm impact of the ensuing trauma requires continued rigorous study and further expansion of multidisciplinary efforts. Keywords

Child maltreatment · Child abuse · Physical abuse · Sexual abuse · Neglect · Emotional abuse/psychological maltreatment · Teen dating violence · Forensic interviewing · Mandated reporting · Child protection · Bullying · Cultural issues The true character of a society is revealed in how it treats its children. –Nelson Mandela

Introduction The maltreatment and victimization of children and adolescents is a national public health crisis. The mission of the National Partnership to End Interpersonal Violence Across the Lifespan (NPEIV) is to make the prevention of interpersonal violence a national priority and to encourage healthy relationships by linking science, practice, policy, and advocacy (NPEIV 2020, www.npeiv.org). To this end, this part on child and adolescent maltreatment utilized NPEIV’s partnerships with many of the leading child abuse researchers, practitioners, and advocates to offer a broader multidisciplinary, cross-cultural understanding of the issues faced by children and youth who experience interpersonal violence. This chapter provides a brief summary on the spectrum of topics someone must consider when entering or working in the field of child and adolescent maltreatment.

Historical Review of Child Abuse and Child Protection Historically, children have been the property of their parents, particularly their fathers, and they did not have rights. Not until the establishment of the Child Abuse Prevention and Treatment Act (CAPTA) of 1974 did the United States have

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an organized governmental process for addressing child victims of maltreatment. Although the US Congress has amended and reauthorized CAPTA numerous times since 1974, children’s rights remain limited. ▶ Chapter 75, “The Law and Policy of Child Maltreatment,” provides a detailed timeline of the laws governing both the civil and criminal responses to child maltreatment. It offers a constitutional framework for legal intervention into the family, including the states’ mandates for child protection as well as the procedural rights of parents and children to keep safe from harm. Under the United Nations Convention on the Rights of the Child (United Nations 1990), children have three categories of rights: (1) protection, (2) provision, and (3) participation. However, the United States is the only country in the world that has not ratified this human rights treaty, which in 1990 established the civil, political, economic, social, and cultural rights of children (United Nations 1990). Although there are a number of policies in the United States that govern children’s rights to protection against abuse and neglect as well as provision for food, education, and health care, still approximately 15 million children in America or 21% live in poverty (National Center for Children in Poverty – NCCP 2020); they and many more are not consistently benefitting from these policies. Every federal fiscal year since data was first collected in 1990, the Children’s Bureau of the US Department of Health and Human Services (HHS) reports on child maltreatment statistics. For 2018, it is estimated 1770 children died of abuse and neglect, and 3,534,000 received a child protective services investigation or alternative response (HHS 2020). Yet, based on adult retrospective studies, many more children experience abuse and neglect that is never reported to child protective services. Further complicating matters, the COVID-19 pandemic led to stayat-home orders isolating children with their abusers and away from professionals trained to recognize signs of abuse and neglect. Due to the increase in parental stressors from job loss, homeschooling, death of loved ones and quarantine restrictions impacting our abilities to grieve individually and collectively, in addition to the separation from support systems, children are at greater risk for unreported harms (Vieth et al. 2020). This chapter will outline some of the challenges children and adolescents face when their protection rights are violated. It concludes with recommendations for future trauma-informed research and practice to continue the understanding of and intervention for, this profound public health problem.

Maltreatment and Victimization of Children and Adolescents ▶ Chapter 13, “Overview of Child Maltreatment,” provides a comprehensive overview of child abuse and neglect, including ways of defining and assessing, especially concerning the severity and chronicity of maltreatment experiences. It explains the biopsychosocial effects of maltreatment on child, adolescent, and adult functioning as well as risk factors associated with familial and neighborhood dynamics.

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Child Physical Abuse Due to variability in both the definition and reporting of physical abuse of children worldwide, prevalence rates continue to change; yet, the majority of physical abuse continues to be perpetrated by parent or caregivers (▶ Chap. 14, “Parents Who Physically Abuse: Current Status and Future Directions”). While the scope of the problem is vast, there are various risk factors for victimization, some of which include the age of the child, disabilities, chronic illness, and mental health issues that may elevate the burden of the parent or caregiver (Fortson et al. 2016). It is important to also address the multiple risk factors of perpetration which include parenting issues of age, low-income level, poverty, unemployment, substance abuse and mental health issues, history of abuse and neglect, exposure to community violence and social isolation, among others (Fortson et al. 2016). There remains a need for more methodologically sound research on risk and protective factors if there is to be a significant reduction in physical abuse (▶ Chap. 14, “Parents Who Physically Abuse: Current Status and Future Directions”). Increased education for parents on the harm from corporal punishment is critical and highlights the ways in which societal shifts around the use of corporal punishment have changed over time (▶ Chap. 15, “Corporal Punishment: From Ancient History to Global Progress”). Listening to children who experienced this form of physical violence is of utmost importance. More programming is becoming available to help explain and utilize the evidence contributing to a global movement to eliminate the use of corporal punishment. Programs focused on painless parenting and the creation of no hit zones in hospitals and the no hit homes models are providing critical toolkits for parents, as demonstrated through the work of the American Professional Society on the Abuse of Children (APSAC, www.apsac.org) and the National Initiative to End Corporal Punishment (LeBlanc et al. 2019). Additional forms of physical abuse, such as abusive head trauma, highlight the need for continued work on diagnostic methods, evaluation, and analysis of direct, indirect, and secondary injuries (▶ Chap. 16, “Abusive Head Trauma: Understanding Head Injury Maltreatment”) and improved recognition of the sustained and severe cruelty to a child’s psyche from the use of torture (▶ Chap. 17, “Domestic Child Torture: Identifying Survivors and Seeking Justice”). Additional attention must be paid to the problem of perpetrators failing to be held accountable for torture of children. The prevalence of fractures, burns, and bruises demonstrate the importance of advanced education of healthcare professionals in identifying when these injuries are likely to be the result of abuse. Enhanced assessment and multidisciplinary team involvement are recommended for instances of inflicted trauma to the abdomen and thorax (▶ Chap. 21, “Inflicted Thoracoabdominal Trauma”), the second leading cause of death due to child physical abuse. A particularly complicated form of child abuse is Munchausen Syndrome by Proxy, which occurs when a child is presented for medical care for a condition that is

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not true (▶ Chap. 22, “Munchausen Syndrome by Proxy”). Unnecessary tests and procedures conducted on the child inflict harm and research shows that their own mothers, many of whom have some background in the medical field, abuse the vast majority of children maltreated in this way. The abuse of children that results in death has for decades been responded to by the work of Child and Youth Fatality Review Teams (CFRTs). ▶ Chapter 25, “Child and Youth Fatality Review,” suggests these teams are of vital importance to the development of a national data system that works to improve the prevention of these deaths. Much can be learned by the examination of the prevention of child physical abuse and the promotion of protective factors as outlined in ▶ Chap. 24, “Child Physical Abuse: A Pathway to Comprehensive Prevention,” works on primary to quaternary strategies.

Neglect Along the continuum of the maltreatment of children and adolescents are the numerous forms of neglect including emotional, medical, and educational harm, among others. ▶ Chapter 26, “The Etiology of Child Neglect and a Guide to Addressing the Problem,” explores neglect as the most commonly reported form of maltreatment to child protective services and the harm endured when a child’s basic needs are not met. ▶ Chapter 26, “The Etiology of Child Neglect and a Guide to Addressing the Problem,” emphasizes the need for more research on neglect, calling for a remedy to the “neglect of neglect.” Neglect also occurs when there is exposure to intimate partner violence (IPV) that is taking place in the home, and neglect also encompasses medical, educational, and emotional neglect among others (▶ Chap. 28, “Child Neglect”). The neurodevelopmental outcomes for children who are neglected and the physical and mental health problems that result from neglect can become lifelong problems for the children involved. Therefore, it must be addressed and further examined (▶ Chap. 28, “Child Neglect”). Dental neglect is another specific form which Brownlee et al. in Chap. 29, “▶ Dental Neglect,” defines in addition to their exploration of proposed assessment scales. Dental neglect contributes to reduced overall individual health. Improving the identification of dental neglect by healthcare professionals is an important step in attending to the health and safety needs of children. The consequences surrounding the failure to protect children from maltreatment results in negative outcomes across several domains on individual, intergenerational, and societal levels. ▶ Chapter 50, “Implications of Maltreatment for Young Children,” explores the research that documents the connection of adverse childhood experiences (ACEs) with trauma and poor physical and mental health outcomes later in life. The developmental trauma experienced by children is significant as well as the transmission of interpersonal violence across generations when abuse and trauma are unidentified and unaddressed.

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Sexual Abuse Although the sexual abuse of children is as old as the human species, the sexual abuse of children was often minimized (▶ Chap. 30, “Sexual Abuse of Children”). In the 1980s this began to change with new and better research that included a deeper understanding of how children disclose abuse, how to interview them, and how to collect evidence (▶ Chap. 30, “Sexual Abuse of Children”). One factor that affects the ability of children to share a history of abuse is not only the level of support they receive from professionals but also from their caregivers (▶ Chap. 32, “Succeeding with Nonoffending Caregivers of Sexually Abused Children”). Common reactions caregivers frequently express after a disclosure of child sexual abuse are often misinterpreted by professionals, and thus it is critical to properly educate these professionals to work with nonoffending caregivers (▶ Chap. 32, “Succeeding with Nonoffending Caregivers of Sexually Abused Children”). In as many as one-third of child sexual abuse cases, the perpetrator is also a child or adolescent (▶ Chap. 33, “Recognizing and Responding to Developmentally Appropriate and Inappropriate Sexual Behaviors of Children: A Primer for Parents, Youth Serving Organizations, Schools, Child Protection Professionals, and Courts”). It is critical for child protection professionals to understand the research on normal versus concerning sexual behaviors of youth in order to determine which cases warrant a professional intervention. This includes screening for trauma, and determining which cases simply need caregiver education to properly address the behaviors (▶ Chap. 33, “Recognizing and Responding to Developmentally Appropriate and Inappropriate Sexual Behaviors of Children: A Primer for Parents, Youth Serving Organizations, Schools, Child Protection Professionals, and Courts”). In some cases, a child may be both a victim and an offender and this calls for special considerations for multidisciplinary teams responding to this dynamic (▶ Chap. 33, “Recognizing and Responding to Developmentally Appropriate and Inappropriate Sexual Behaviors of Children: A Primer for Parents, Youth Serving Organizations, Schools, Child Protection Professionals, and Courts”). We also need to continually examine the assessment and treatment of this population and look for new approaches to assessing the risk of sexually abusive youth (▶ Chap. 36, “State-ofthe-Art Measures: Contemporary Views on Risk Assessment of Sexually Abusive Youth”). With respect to adults who sexually offend against children, men have often been divided into situational offenders (those who take advantage of an opportunity) and preferential offenders (those who seek out children for sexual purposes) (▶ Chap. 35, “Adult Sex Offenders Against Children: Etiology, Typologies, Investigation, Treatment, Monitoring, and Recidivism”). However, a number of studies find that offenders who initially present as one type of offender often fit into multiple categories (▶ Chap. 35, “Adult Sex Offenders Against Children: Etiology, Typologies, Investigation, Treatment, Monitoring, and Recidivism”). Although we do not know as much about female sex offenders, these women often have histories of abuse, have mental health issues, and are dependent on others (▶ Chap. 35, “Adult Sex Offenders Against Children: Etiology, Typologies, Investigation, Treatment,

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Monitoring, and Recidivism”). Being sexually abused by a female may intensify the fear of some victims that they will not be believed, and it is certainly true there are many biases in multidisciplinary teams (MDTs) about offenses committed by females (▶ Chap. 35, “Adult Sex Offenders Against Children: Etiology, Typologies, Investigation, Treatment, Monitoring, and Recidivism”). Children who are in a correctional or other institutional setting are particularly vulnerable, and there is evidence that some adult offenders infiltrate these settings for the purpose of sexually abusing youth (▶ Chap. 38, “Abuse of Youth in Residential Settings/Institutions”). There is a growing awareness of factors that place sexual and gender minority youth at greater risk for sexual victimization and a deeper awareness of the barriers these youth face to accessing services (▶ Chap. 34, “The People in Your Neighborhood: Working with Sexual and Gender Minority Youth as Victims of Sexual Violence”). There is also a greater understanding of the use of technology in sexually exploiting youth as well as an awareness of how this technology can be employed to generate evidence and protect children from these offenders (▶ Chap. 39, “Technology-Facilitated Child Abuse”). Technology is one of many tools used by offenders in creating sexually exploitive images, in trafficking children, and in sex tourism (▶ Chap. 37, “The Commercial Sexual Exploitation of Children”). In cases of child sexual abuse, most examinations do not produce medical evidence of a sexual assault, though there are some mimickers of child sexual abuse and, in a minority of cases there are positive findings of trauma (▶ Chaps. 40, “Genital Examination Techniques”; ▶ 44, “Mimickers of Child Sexual Abuse” and ▶ 42, “Acute Sexual Assault Evaluation of the Prepubertal Child”). Even when there are not positive medical findings of child sexual abuse, the examination may provide comfort to a child victim as a medical professional assures the child their body is free of disease or injury. Negative findings can also assist the government in prosecuting a case of sexual abuse. This is because the examiner can explain to a judge or jury that the absence of medical evidence does not mean the child was not abused. Indeed, the absence of evidence, provided it is consistent with the history the child has provided, may serve as corroborating evidence depending on the specific aspects of the abuse alleged (Vieth 2014).

Emotional Abuse While attention is often focused on the physical abuse and neglect of children, the trauma created from psychological maltreatment is significant and often long lasting, consisting of a pattern or extreme incident(s) by a caretaker that impede a child’s psychological needs and demonstrate to the child that they are unwanted, unloved, and defective (Brassard et al. 2019). Different forms of psychological maltreatment include spurning, terrorizing, exploiting, abandoning, denigrating, and being emotionally unresponsive, among others. ▶ Chapters 45, “Psychological Maltreatment of Children: Influence Across Development,” and ▶ 46, “Psychological Maltreatment of Children and Youth: A Historical Perspective on the Right to Be Emotionally Safe” delve into this form of

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interpersonal abuse and trauma, reviewing findings on risk factors and prevalence rates along with the impact of psychological maltreatment across developmental outcomes. The right to be emotionally safe is examined and also how culture and intention affect the ways in which psychological maltreatment is handled. Important attention is paid to the concept of the human rights of children. Finally, bullying and cyberbullying are additional examples of the ways that children and youth are being negatively impacted. Over the past two decades, research on the various ways that youth experience bullying has grown significantly, helping to inform and advance the efficacy of prevention and intervention efforts (▶ Chap. 47, “Bullying and Cyberbullying Throughout Adolescence”). These forms of interpersonal violence must also include analysis of gender differences and increased education for professionals on the resulting trauma for youth who have been victimized. The experience of cyberbullying is complex given the regular exposure of youth to abuse through online platforms and forums, which can often leave parents unaware of and unprepared for the dangers of these technologyfacilitated crimes (https://www.stopbullying.gov/cyberbullying/prevention). The prevention of physical abuse, neglect, and emotional abuse of children and youth requires multidisciplinary coordinated action. Increased understanding of risk and protective factors are critical to aid in the prevention of the various ways children’s minds, bodies, and spirits are suffering. Much of the work to be done remains in advancing parenting skills and changing social norms that contribute to the maltreatment of children and youth (Klika and Linkenbach 2019). More attention and research dedicated to the resilience of children and adolescents is needed to expand the understanding of the developmental impact and intergenerational transmission of these forms of abuse and neglect. We need to continue to work together to not only prevent all abuse and neglect but also increase our efforts to protect and nurture the emotional and physical development, safety, and promise of the next generation.

Family Violence and Teen Dating Violence Children exposed to IPV are affected in a multitude of ways and can suffer severe difficulties across the spectrum, including emotionally/psychologically, behaviorally, developmentally, and cognitively. They also can experience long-term healthrelated problems in adulthood. According to the Centers for Disease Control, exposure to or witnessing IPV is considered an ACE. ACEs have been linked to risky health behaviors, chronic health conditions, potential for low quality of life, and early death (▶ Chap. 5, “Adverse Childhood Experiences: Past, Present, and Future”). Children’s exposure to IPV includes what they hear as well as what they see. Within their home environment, there is an atmosphere of fear and intimidation. Children often see the physical signs of domestic violence, including physical injury to family members and damage to property. In homes where IPV is occurring, children are at greater risk for experiencing physical abuse themselves (Stiles 2002).

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Additionally, young children can suffer with sleep disturbances such as nightmares, poor sleeping habits, and night waking. They can exhibit immature or regressed behavior as well as physical complaints and poor health. Young children exposed to IPV can also suffer with: emotional distress (i.e., crying, irritability, insecurity, hyperactivity); loss of developmental skills (i.e., toileting, language); and struggle with becoming withdrawn, aggressive, and/or allow others to bully them (Stiles 2002). Witnessing IPV and experiencing sibling violence increases the likelihood of experiencing Teen Dating Violence (TDV), as well as developing aggressive behaviors and other mental health issues (▶ Chap. 52, “Youths’ Exposure to Violence in the Family”). Although many adolescents can recount witnessing IPV in their home, many are unprepared for violence with their own relationships with intimate partners. TDV is not a new phenomenon but is multidimensional and includes all aspects of IPV including physical, psychological, sexual, online, and stalking behaviors. It has been historically understudied by researchers and under-examined by practitioners (▶ Chap. 55, “Teen Dating Violence and Stalking”).

Cultural Issues The countless children and youth who are abused, neglected, and traumatized who never come to the attention of reporting authorities are invisible victims. The disproportionate rate of abuse and neglect of children of color, particularly African-American children, must be prioritized and changes made to our current policies and systems that examine the numerous factors on community and societal levels contributing to the violence and trauma these children experience. Factors such as race, ethnicity, and income level among others, contribute to the exposure of children to abuse (HHS 2015). Children are often exposed to a variety of traumatic experiences. Best practice dictates that all professionals working with at-risk youth and victims of child maltreatment are trauma-informed as well as collaboratively trained. The forensic interview is a critical tool in gathering information about the trauma children have experienced. Yet, barriers created by interviewer behavior, as well as external, developmental, and cultural differences can interfere with the ability to gain vital information. When working with culturally diverse children, it is important professionals utilize an interdisciplinary collaboration to avoid misunderstandings and misinformed decision-making when interviewing child victims. Becoming culturally competent means being knowledgeable about abuse and cultural issues, behaving ethically and responsibly, as well as following state laws and federal mandates. As one example, children sometimes pose religious questions in a forensic interview and these questions often highlight the need for Children’s Advocacy Centers and faith leaders to work collaboratively to address a child’s spiritual needs and to do so within the child’s cultural framework (Tishelman and Fontes 2017). When addressed in a culturally sensitive manner, spirituality is a critical source of resiliency for many abused children (▶ Chap. 77, “Responding to Child Abuse

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During a Pandemic”). Given this fact, some Children’s Advocacy Centers have hired trauma-informed chaplains who can assist in meeting the spiritual needs of maltreated children and to develop bridges between the MDT and local faith leaders (Vieth et al. 2020). Professionals acquire and develop cultural competency by being open and willing to learn about not only their own culture but that of others. This can be done by attending conferences, educational activities, supervision, consulting with colleagues, and exploring his/her own preferences and prejudices. As ▶ Chap. 58, “Cultural Competence in the Field of Child Maltreatment,” explains, professionals need to approach children and families with cultural humility if they are to help them avoid or recover from child abuse and neglect. Cultural competence requires a commitment to an ongoing process.

Consequences and Interventions Since the inception of CAPTA, the investigation of child abuse has taken dramatic steps forward to fully recognize the incidence of child abuse and neglect affecting American youth. Consequently, research to improve efforts on how to effectively intervene has increased exponentially. One of the most significant interventions has focused on how to elicit accurate information from children regarding abuse and neglect, a technique referred to as forensic interviewing (Newlin et al. 2015). Following 40 years of research and practice by pioneers in the field, significant strides have been made in maximizing the potential of children to accurately convey information. Yet, as this effort continues, new challenges arise; therefore, improvements in the field of forensic interviewing must remain steadfast (▶ Chap. 65, “Forensic Interviewing”). The child forensic interview has been a crucial component in the investigation of suspected child abuse in the United States. Prior to this, social service and criminal justice systems did not effectively coordinate their efforts in response to allegations of child sexual abuse. In 1985, former Congressman Robert Cramer (AL), then a District Attorney, organized the Child Advocacy Center (CAC) model, bringing together law enforcement, child protective services, prosecution, victim advocates, and medical and mental health professionals onto one coordinated team. More than 900 communities have adopted this multidisciplinary response to child abuse across the United States and throughout the world (▶ Chap. 65, “Forensic Interviewing”). As the CAC model expanded, the importance of conducting a forensically defensible interview as well as an interview that was developmentally appropriate for the age of the child became clear. The National Children’s Alliance (NCA) established Standards for Accredited Members, including a standard for those conducting child forensic interviews to have formal (initial and ongoing) forensic interviewer training (Newlin et al. 2015). Hence, a number of training programs have

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developed (Faller 2015), and it is now widely accepted that professionals should have appropriate forensic interview training in order to provide this essential service (▶ Chap. 65, “Forensic Interviewing”). ▶ Chapter 66, “Linking Trauma-Informed Screening and Assessment Practices Across Child-Serving Systems,” emphasizes that professionals must utilize traumainformed screening and assessment practices within their agencies if they are to meet the complex needs of maltreated children and adolescents. In addition, professionals need to learn the distinctive types and purposes of these tools if they are to be effective. When using a trauma-informed framework, a number of factors should be considered, such as evidence-based options that allow for data-driven outcomes, a structured process that considers well-being as well as cultural and developmental needs, and a system to increase sustainability of ongoing practices (▶ Chap. 66, “Linking Trauma-Informed Screening and Assessment Practices Across Child-Serving Systems”).

Recognizing and Responding According to ▶ Chap. 72, “Child Welfare System: Structure, Functions, and Best Practices,” most studies have found no impact from child welfare services (CWS) on child abuse outcomes such as improving maltreatment recurrence. However, when empirically supported interventions (ESIs) are used with CWS populations, studies indicate effectiveness. Unfortunately, the use of ESIs is not yet widespread (▶ Chap. 72, “Child Welfare System: Structure, Functions, and Best Practices”). Cross and Risser (▶ Chap. 72, “Child Welfare System: Structure, Functions, and Best Practices”) identified several ESIs that have been successful in the reduction of child behavior problems when used with families who have CWS involvement due to physical abuse: Parent–Child Interaction Therapy (PCIT, pcit.org), the Positive Parenting Program (Triple P, triplep.net), the Incredible Years (incredibleyears.com), and Alternatives for Families: A Cognitive Behavioral Therapy (AF-CBT, afcbt.org). These interventions teach parents how to manage their child’s behavior by using noncoercive, nonviolent discipline methods, which reduces engaging in responses that can escalate to physical abuse. Sullivan et al. in ▶ Chap. 73, “The Child Welfare System: Problems, Controversies, and Future Directions,” state there are other problems with the current child welfare system beyond the issue of an inconsistent use of evidence-based practices. They acknowledge the system’s poor outcomes are also related to racial disproportionality, insufficient governmental commitment, and lack of community support, as well as problems with organizational culture and climate. They believe the future of the child welfare system is dependent in part on the incorporation of trauma-informed services, reduction of workload, and the implementation of universal and primary prevention approaches that support families and communities.

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Key Points • Maltreatment and victimization of children and adolescents is a national public health crisis. • A broader multidisciplinary, cross-cultural understanding of the issues faced by children and youth who experience interpersonal violence is needed. • United States remains the only country that has not ratified the United Nations Convention on the Rights of the Child; therefore, US children have limited rights under the law. • In 2018, 1770 children died of abuse and neglect, and 3,534,000 received a child protective services investigation or alternative response (HHS 2020) while many incidences of abuse and neglect remain unreported. • Risk factors for victimization and perpetration are key considerations in physical, sexual and psychological abuse, and neglect as are protective factors. • Future research is needed as are trauma-informed prevention and intervention methods and inclusion of cultural considerations and cultural humility. • ACEs create physical and mental health problems for children who are abused and neglected, including negative impacts on developmental and neurodevelopmental outcomes. • Trauma-informed services, multidisciplinary efforts, and implementation of universal and primary prevention approaches in the child welfare system are critical in the response to child and youth maltreatment and neglect.

Summary and Conclusion The abuse and neglect of children in the United States is an urgent public health problem necessitating the response of not only medical and mental health professionals but also criminal justice, social services, faith communities, and policymakers. Indeed, each citizen has a role in addressing this crisis, if only through our decisions at the ballot box. On January 23, 1973, then United States Senator Hubert Humphrey told his senate colleagues: Child abuse has been ignored because it is something we would all like to pretend doesn’t exist. And child abuse has been ignored because children have no political muscle, no effective way of articulating their needs to those of us who write the law. (Engelmayer and Wagman 1978, p. 313)

Although no reputable politician favors child abuse, Humphrey reminds us that many governmental leaders fail to prioritize funding or take other legislative action simply because children cannot vote, and because adult voters fail to demand action. ▶ Chapter 75, “The Law and Policy of Child Maltreatment,” underscores that child maltreatment is a social problem relegated to individual states. The federal government provides funds as a means to govern how individual states manage their civil and criminal responses to child abuse and neglect (▶ Chap. 75, “The Law and Policy

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of Child Maltreatment”). Given the state and federal role in the United States in addressing maltreatment, voters should urge candidates for state and federal office to clearly articulate their commitment to addressing the abuse of children. Annually, child protection agencies receive reports of allegations of abuse and neglect of millions of children in the United States, with almost three-quarters of a million of those cases to be investigated and verified (HHS 2020). The federal government sets policy and assesses the performance of state child welfare agencies. However, child welfare agencies must consistently use empirically supported interventions and training for staff. This may necessitate significant improvement of training at the undergraduate and graduate level and transitioning to simulationbased training once workers are in the field (Vieth et al. 2019). The research on ACEs demonstrates that many parents were victims themselves and are often doing the best they can, considering issues of unresolved intergenerational family violence and resulting trauma. Now, in midst of the COVID-19 pandemic, parents are even more overwhelmed dealing with loss of employment, evictions, and food insecurity. Many lack the education and/or training to understand much of what their children are learning in formal school environments, so homeschooling has only added to their stress. Trauma-informed care for families can assist in managing the anxiety and stress, and reduce the incidents of abuse. However, the United States and many other countries desperately need a universal means of reducing childhood poverty, which is a contributing factor to many forms of child maltreatment. Since child abuse also contributes to poverty, as well as numerous medical and mental health conditions, any reduction in maltreatment will also have a profound impact on our society. Although Hubert Humphrey lamented the obstacles confronting us in addressing child abuse, he also sounded a note of optimism, concluding that “Each child is an adventure into a better life – an opportunity to change the old pattern and make it new” (Geddes 2005, p. 12). Our nation’s legacy of child abuse does not have to be our future. The chapters in this part of the Handbook offer readers a new pattern of responding to child abuse, and the realistic hope of significantly reducing if not eliminating abuse of children and adolescents.

References Brassard, M. R., Hart, S. N., Baker, A. A. L, & Chiel, Z. (2019). The APSAC monograph on psychological maltreatment (PM). The American Professional Society on the Abuse of Children (APSAC). Retrieved from: https://www.apsac.org Engelmayer, S. D., & Wagman, R. (1978). Hubert Humphrey: The man and his dream 1911–1978. New York: Methuen. Faller, K. C. (2015). Forty years of forensic interviewing of children suspected of sexual abuse, 1974–2014: Historical benchmarks. Social Sciences, 4, 34–65. Fortson, B. L., Klevens, J., Merrick, M. T., Gilbert, L. K., & Alexander, S. P. (2016). Preventing child abuse and neglect: A technical package for policy, norm, and programmatic activities. Atlanta: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Geddes, A. (2005). Cherished thoughts with love. Kansas City: Andrews McMeel Publishing.

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Klika, J. B., & Linkenbach, J. W. (2019). Social norms and violence against children and youth: Introduction to the special issue. Child & Adolescent Social Work Journal, 36, 1–3. https://doi. org/10.1007/s10560-018-0596-7. LeBlanc, S., Alexander, R., Mastrangelo, M., & Gilbert, H. (2019). No hit zones: A simple solution to address the most prevalent risk factor in child abuse. APSAC Advisor, 31(1), 37–51. National Center for Children in Poverty (NCCP). (2020). Child poverty. http://www.nccp.org/ topics/childpoverty.html#:~:text¼About%2015%20million%20children%20in,underestimate% 20the%20needs%20of%20families.&text¼Research%20is%20clear%20that%20poverty,threat %20to%20children’s%20well%2Dbeing National Partnership to End Interpersonal Violence Across the Lifespan (NPEIV). (2020). Our mission. https://www.npeiv.org/ Newlin, C., Steele, L. C., Chamberlin, A., Anderson, J., Kenniston, J., Russell, A., Stewart, H., & Vaughan-Eden, V. (2015). Child forensic interviewing: Best practices. Washington, DC: Office of Juvenile Justice and Delinquency Prevention (OJJDP) Bulletin. Stiles, M. (2002). Witnessing domestic violence: The effect on children. American Family Physician, 66(11), 2052–2066. Tishelman, A. C., & Fontes, L. A. (2017). Religion in child sexual abuse forensic interviews. Child Abuse & Neglect, 63, 120–130. United Nations Office of the High Commissioner for Human Rights. (1990). Convention on the rights of the child. New York: United Nations Retrieved from: https://www.ohchr.org/en/ professionalinterest/pages/crc.aspx United States Department of Health and Human Services (HHS), Administration for Children and Families, Youth and Families, Children’s Bureau. (2015). Child maltreatment 2013. Washington, DC: Government Printing Office. Retrieved from: http://www.acf.hhs.gov/sites/ default/files/cb/cm2013.pdf U.S. Department of Health & Human Services (HHS), Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2020). Child maltreatment 2018. Washington, DC: Government Printing Office. Available from: https://www.acf.hhs. gov/cb/research-data-technology/statistics-research/child-maltreatment Vieth, V. (2014). Investigating and prosecuting cases of child abuse. In D. Chadwick, R. Alexander, A. Giardino, D. Esernio-Jenssen, & J. Thackery (Eds.), Chadwick’s child maltreatment (pp. 179–222). St. Louis: STM Learning. Vieth, V. I., Goulet, B., Knox, M., Parker, J., Johnson, L. B., Tye, K. S., & Cross, T. P. (2019). Child Advocacy Studies (CAST): A national movement to improve the undergraduate and graduate training of child protection professionals. Mitchell Hamline Law Review, 45(4), Article 5. Available at: https://open.mitchellhamline.edu/mhlr/vol45/iss4/5 Vieth, V. I., Everson, M. D., Vaughan-Eden, V., Tiapula, S., Galloway-Williams, S, & Nettles, C. (2020). Keeping faith: The potential role of a chaplain to address the spiritual needs of maltreated children and advise child abuse multi-disciplinary teams. Liberty University Law Review, 14(2), Article 5. Available at: https://digitalcommons.liberty.edu/lu_law_review/vol14/iss2/5

Overview of Child Maltreatment

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Defining and Assessing Child Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Types of Child Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Ways to Conceptualize Child Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Consideration of Assessment Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Consequences of Child Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Introduction to Child Maltreatment Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychological Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Behavioral Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physical Health Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Resilience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mechanisms of Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Economic Costs of Child Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Risk Factors for and the Context of Child Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Parental and Caregiver Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Familial Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Neighborhood Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Limitations and Future Considerations in Child Maltreatment Research and Practice . . . . . . . . Limitations in Child Maltreatment Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Future Considerations in Child Maltreatment Research and Practice . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. K. Donisch · E. C. Briggs (*) Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_8

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Abstract

Child maltreatment is a considerable public health problem in the United States due to its impact on the affected youth, their families and communities, as well as greater society. The possible consequences of child maltreatment are staggeringly complex, as the effects of abuse and neglect often cascade throughout the life course. While some youth exhibit adverse effects in many areas of human functioning, including psychological, behavioral, and physical health, others may evince few, if any, difficulties. Regardless, a predominant barrier to the assessment, prevention, and treatment of child maltreatment is the lack of clarity in defining and operationalizing the primary and associated terms. Broadly, however, child abuse generally refers to acts of commission such as sexual abuse, physical abuse, and psychological (or emotional) abuse, whereas neglect refers to acts of omission, including both the failure to provide and supervise. This chapter presents an overview of child maltreatment, including ways of defining and assessing maltreatment, particularly with respect to the severity and chronicity of maltreatment experiences. The effects of maltreatment on child, adolescent, and adult functioning will be examined, including psychological, behavioral, and physical health domains. Risk factors for and the larger context in which child abuse and neglect occurs will also be discussed, with emphasis on parental and caregiver, familial, and neighborhood risk factors. The chapter concludes with recommendations for future research and practice to continue to advance the understanding of, and intervention for, this profound public health problem. Keywords

Child maltreatment · Sexual abuse · Physical abuse · Emotional abuse · Neglect · Developmental psychopathology · Resilience · Protective factors · Risk factors

Introduction Child maltreatment is a considerable public health problem in the United States due to its impact on the affected youth, their families and communities, as well as greater society. Indeed, the effect of maltreatment on the mental and physical health, social, and economic functioning of survivors is well established. Data from 2017 indicate that approximately 3.5 million children were identified as possible victims of child maltreatment through child protective services (United States Department of Health and Human Services [USDHHS] 2019). An estimated 17% of these children and adolescents were determined to be substantiated victims of child abuse and neglect or 9.1 victims per 1,000 children in the population. However, this only represents the children and adolescents who came to official attention, suggesting that these statistics are likely a significant underestimate of the problem. Estimates from the most recent National Incidence Study of Child Abuse and Neglect indicate that

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the rate of child abuse and neglect by caregivers was 17.1 of every 1,000 children in the population from 2005 to 2006 nationwide, suggesting variable rates of risk (Sedlak et al. 2010). The possible consequences of child maltreatment are staggeringly complex, as the effects of abuse and neglect often accumulate and cascade across stages of development. While some youth exhibit adverse effects in many areas of human functioning, including psychological, behavioral, and physical health, others may evince few, if any, difficulties. Indeed, for many children and adolescents, these possible negative outcomes are also impacted by normative developmental tasks and challenges, as well as the larger context in which the maltreatment occurs (e.g., family hardship, neighborhood characteristics). This chapter presents an overview of child maltreatment, including ways of defining and assessing maltreatment, as well as the effects of maltreatment on child, adolescent, and adult functioning. The larger context in which child abuse and neglect occurs will also be discussed, and the chapter concludes with recommendations for future research and practice to continue to advance the understanding of, and intervention for, this profound public health problem.

Defining and Assessing Child Maltreatment A predominant barrier to the assessment, prevention, and treatment of child maltreatment is the lack of clarity in defining and operationalizing the primary and associated terms. Therefore, a critical step in understanding the complex relationships between child maltreatment and its antecedents and consequences is to carefully define and operationalize both child abuse and neglect. Broadly, child maltreatment includes acts of commission and omission that result in actual harm, potential harm, or threat of harm to a child or adolescent, although there is some variation by state (Leeb et al. 2008). Regardless, all states, the District of Columbia, and the Commonwealth of Puerto Rico broadly conform in some way to definitions proposed in the 2010 reauthorization of the Child Abuse Prevention and Treatment Act (CAPTA; P.L. 111–320) that minimally describes child maltreatment as: Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act, which present an imminent risk of serious harm. (USDHHS 2019, p. 102–103)

Each state and territory has developed its own definitions for the specific types of child abuse and neglect. While child abuse generally refers to acts of commission such as sexual abuse, physical abuse, and psychological (or emotional) abuse, neglect, in contrast, refers to acts of omission, including both the failure to provide and supervise. In practice, most definitions of maltreatment types are similar to those used by both CAPTA and the Centers for Disease Control (CDC; Leeb et al. 2008), which are presented in Table 1.

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Table 1 Definitions of maltreatment types proposed by the Child Abuse Prevention and Treatment Act (CAPTA) and the Centers for Disease Control (CDC) Type of Maltreatment Sexual abuse

Physical abuse

Psychological or emotional abuse

Neglect – failure to provide

Neglect – failure to supervise

CAPTA Definitions The involvement of the child in sexual activity to provide sexual gratification or financial benefit to the perpetrator, including contacts for sexual purposes, molestation, statutory rape, prostitution, pornography, exposure, incest, or other sexually exploitative activities (p. 114) Physical acts that caused or could have caused physical injury to a child (p. 111) Acts or omissions – other than physical abuse or sexual abuse – that caused or could have caused conduct, cognitive, affective, or other behavioral or mental disorders. Frequently occurs as verbal abuse or excessive demands on a child’s performance (p. 112) Deprivation of necessities or failure by the caregiver to provide needed, age-appropriate care although financially able to do so or offered financial or other means to do so (p. 109) n/a

CDC Definitions Any completed or attempted (noncompleted) sexual act, sexual contact with, or exploitation (i.e., noncontact sexual interaction) of a child by a caregiver (p. 15)

The intentional use of physical force against a child that results in, or has the potential to result in, physical injury (p. 14) Intentional caregiver behavior that conveys to a child that he/she is worthless, flawed, unloved, unwanted, endangered, or valued only in meeting another’s needs (p. 16)

Failure by a caregiver to meet a child’s basic physical, emotional, medical/dental, or educational needs – or combination thereof (p. 17)

Failure by the caregiver to ensure a child’s safety within and outside the home given the child’s emotional and developmental needs (p. 18)

Types of Child Maltreatment The sexual abuse of children not only includes sexual acts and contact but also noncontact sexual interactions. Specifically, sexual acts are characterized by penetration between the mouth, penis, vulva, or anus of a child by another individual, as well as penetration of a child’s genital or anal opening by a hand, finger, or other object. Sexual contact, in contrast, refers to any intentional touching, either directly or through the clothing, of a child’s genitalia, anus, groin, breast, inner thigh, or buttocks. As the term suggests, noncontact sexual interactions do not include physical contact between a caregiver and a child and, instead, are exemplified by intentional exposure to pornography or exhibitionism, filming in a sexual manner, sexual harassment, commercial exploitation (i.e., prostitution) of a child, or sex trafficking (Leeb et al. 2008, p. 15). In the United States, sexual abuse constitutes

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8.6% of all officially substantiated child abuse cases (USDHHS 2019), although estimated prevalence rates are generally much higher. Indeed, lifetime prevalence rates of sexual abuse by early adulthood range from 30% to 40% of female children and 13% of male children (Bolen 2001). Sexual abuse is also recognized as the most underreported form of child maltreatment with research suggesting that approximately 60% of children and adolescents do not disclose experiences of sexual abuse until adulthood (Alaggia 2004). Underreporting occurs for a variety of reasons, yet the consequences not only impact the immediate protection of children, but also the economic and political resources needed for maltreatment prevention and intervention. Physical abuse refers to acts in which a parent or caregiver caused or could have caused physical injury to a child through a variety of acts including, but not limited to, hitting, kicking, punching, beating, stabbing, shaking, strangling, smothering, burning, poisoning, or otherwise inflicting injury on a child (Leeb et al. 2008; USDHHS 2019). In 2017, physical abuse accounted for 18.3% of officially reported child abuse cases in the United States (USDHHS 2019), whereas the prevalence rate of self-reported child physical abuse internationally is estimated to be 23% (Stoltenborgh et al. 2013). Much of the research on child physical abuse has focused on child-rearing and discipline techniques, with unpleasant caregiving behaviors on one end of the continuum and physical abuse at the other end. However, there is evidence that parents who physically discipline their children (e.g., spank) are approximately three times as likely to report harsher disciplinary acts consistent with child physical abuse (Zolotor et al. 2008). Therefore, exploring the normative values that shape parents’ beliefs about the use of harsh discipline may inform existing prevention and treatment models. Findings related to racial and ethnic differences suggest that minority status may confer greater risk of physical abuse, as prevalence rates of physical abuse have been found to differ by race and ethnicity. For example, higher rates of harmful child physical abuse were found for Black/ African American children compared with children identifying as Hispanic/Latinx or White in the Fourth National Incidence Study of Child Abuse and Neglect (NIS-4; Sedlak et al. 2010). Contrastingly, the National Survey of Adolescents-Replication found that youth who identified as Hispanic/Latinx, African American, and Native American were more likely than White youth to report child physical abuse, with Hispanic/Latinx youth reporting the highest prevalence rates (Hawkins et al. 2010). Of course, these findings should be interpreted with caution given that numerous variables may be collinear with race and ethnicity, including socioeconomic status, educational level, and employment status. Psychological or emotional abuse is difficult to define, however, is generally characterized by caregiver behavior that conveys to a child or adolescent that he or she is worthless, flawed, unloved, unwanted, endangered, or valued only in meeting another’s needs (Leeb et al. 2008). While some experts posit that emotional abuse frequently occurs as verbal abuse, emotionally abusive behaviors also include spurning, exploiting/corrupting, terrorizing, isolating, being emotionally unresponsive, or otherwise behaving in a manner that is harmful, potentially harmful, or insensitive to a child’s developmental needs. Within its definition of emotional

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abuse, the National Child Abuse and Neglect Data System (NCANDS) – funded through CAPTA – also places importance on the potential effects of such behavior in that the caregiver’s actions may be related to a child’s affective, behavioral, cognitive, conduct, or other mental disorders. Given that emotion abuse is difficult to define, it is also difficult to identify reliably, which results in considerable variation among states in their rates of evaluation and reporting. For instance, although 5.7% of substantiated child maltreatment reports were attributed to psychological maltreatment in 2017, rates of psychological maltreatment vary from 0% to 62.3% across state lines (USDHHS 2019). Compared to other types of child maltreatment, such as child sexual and physical abuse, emotional abuse is also less likely to be investigated, as community sample studies estimate rates of caregiver psychological aggression may be as high as 80% denoting that emotional abuse is a more pervasive problem than indicated by some governmental reports (Clément and Chamberland 2007). There are two primary subtypes of child neglect – failure to provide and failure to supervise – which are both characterized as a parent’s or caregiver’s omission of care. As outlined in Table 1, failure to provide includes physical neglect (failure to meet child’s basic needs, including adequate nutrition, hygiene, shelter, and clothing), emotional neglect (denial of emotional responsiveness or access to mental healthcare), medical/dental neglect (failure to provide adequate access to medical, vision, or dental care), and educational neglect (failure to provide access to adequate education). In contrast, the failure to supervise subsumes both inadequate supervision and exposure to violent environments. Examples of inadequate supervision include the failure to ensure that a child engages in safe activities and uses appropriate safety devices, is not exposed to unnecessary hazards, or is appropriately supervised by an adequate substitute caregiver. When a caregiver intentionally fails to take measures to protect a child from pervasive violence within the home (domestic violence), neighborhood, or community, it is deemed exposure to a violent environment. According to 2017 data, neglect has, by far, the highest incidence of all maltreatment types and accounts for approximately 75% of all substantiated maltreatment reports (USDHHS 2019). Moreover, neglect is responsible for most maltreatment-related fatalities in the United States: of the 1,368 children who died from maltreatment in 2017, 75.4% suffered neglect and 41.6% suffered physical abuse either exclusively or in combination with another maltreatment type (USDHHS 2019). Whether the behavior of a parent or caregiver is classified as an act of commission or omission, research indicates that the type of maltreatment has differential effects on child and adolescent outcomes. Although researchers have historically investigated the effects of maltreatment types in isolation, progress has been slow in identifying the precise nature and degree of overlap among maltreatment types due to the tendency to research the effects of a single type of maltreatment and imprecise operational definitions (Herrenkohl and Herrenkohl 2009). Regardless, current examinations of maltreatment suggest comorbidity rates ranging from 21% to 95%, with high rates of co-occurrence between physical and emotional abuse, as well as physical and sexual abuse (Herrenkohl and Herrenkohl 2009). In addition to

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the study of co-occurring trauma types, there has been increasing interest in constellations of trauma type exposures and how these constellations relate to divergent outcomes and trajectories over time (e.g., Pynoos et al. 2014). For example, in a sample of over 14,000 children referred for trauma treatment, a robust constellation of early co-occurring caregiver-induced trauma was discovered, including neglect, emotional abuse, witnessing domestic violence, physical abuse, and exposure to impaired caregiving (i.e., caregiver substance use/abuse, mental illness) (Pynoos et al. 2014). These advanced analyses may assist with the selection and personalization of evidence-based treatments to improve the outcomes of youth exposed to a constellation of maltreatment experiences.

Other Ways to Conceptualize Child Maltreatment Although it is critical to define and review the various types of child maltreatment, other aspects of child abuse and neglect are considered equally as important, namely, the severity, age of onset, duration, and perpetrator type of the abuse or neglect (English et al. 2005). Of these dimensions, the most widely examined of these focus on the severity and chronicity of the experience. It may seem intuitive that the severity of the maltreatment experience would be relevant in the study of child abuse and neglect effects; however, the ability to classify the severity of a child’s experience is confounded by both individual and situational characteristics (Gabrielli et al. 2017). In order to address these characteristics, researchers have developed classification systems to model severity across child maltreatment types (e.g., Modified Maltreatment Classification System). Results from these systems indicate that maltreatment severity, classified in a number of different ways, accounts for a significant proportion of variance in child abuse and neglect outcomes (e.g., Litrownik et al. 2005). Others have shown that maltreatment severity is a stronger predictor of adult trauma symptomatology than total number of maltreatment types (Clemmons et al. 2007). A related, and more common, approach to studying maltreatment severity is to focus on children’s experiences that have been officially recognized and substantiated by child protective services. However, substantiation is a complex and multi-determined process, which is not only influenced by the severity or certainty of the alleged maltreatment but also by the demographic characteristics of the child and family, administrative factors, chronicity and history of abuse, and reporter identity (see English et al. 2002). The temporal pattern of maltreatment is another important dimension to consider when conceptualizing child maltreatment. Chronicity of exposure can be defined in a number of ways, including the duration of a specific maltreatment experience, the proportion of a child’s life in which a type of maltreatment occurred, or the frequency of maltreatment experiences throughout a child’s life (Gabrielli et al. 2017). Chronicity can also refer to whether maltreatment is reported during or across key developmental periods (e.g., infancy, early childhood, middle childhood, adolescence), emphasizing how the risks, antecedents, and consequences of abuse and neglect appear across developmental stages (English et al. 2005).

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Consideration of Assessment Approaches Compounding the issue of how child maltreatment is defined and operationalized is how child maltreatment is assessed, by whom, and when. Historically, researchers have relied on official reports of maltreatment from child protective services, such as NCANDS (USDHHS 2019). However, and as mentioned previously, this approach is constrained by underreporting, as retrospective reports from adults who experienced abuse or neglect as children indicate that a large number of cases are not reported to authorities (Alaggia 2004). When adults are asked why they did not disclose their experience(s) of maltreatment, they specify a variety of barriers. For instance, adults indicate that they did not realize what happened was inappropriate, illegal, or a form of abuse or that they had fears about the individual or familial consequences of reporting the abuse. In fact, once child maltreatment has been disclosed or detected, a host of factors may influence whether adults or other mandated reporters take action, including the failure to recognize signs and symptoms of abuse, beliefs about possible negative consequences resulting from the report (e.g., involvement with child protective services), or uncertainty about child abuse reporting laws and procedures (Alvarez et al. 2004). According to NCANDS, once an individual has made a report to child protective services, approximately 58% of cases are screened in for some type of official response (USDHHS 2019). Again these rates tend to vary by state, as rates of referrals screened in for additional investigation varied from 15.6% in South Dakota to 98.3% in Alabama (USDHHS 2019). Clearly, a large proportion of referrals are screened out given that they may not meet the legal criteria or state standards for child abuse and neglect or because information about the case is simply incomplete or insufficient. If a referral is screened in, it becomes an official report with an associated disposition (finding), which either leads to an investigation or alternative response. Unfortunately, the reliability of substantiation decisions across caseworkers, between county child protective service agencies, and over time is unquestionably poor (Hussey et al. 2005). Only about 17% of referrals to child protective services are classified as substantiated, and, much like rates of referrals that are screened in, rates of substantiation vary considerably across states with minimal agreement on what accounts for this variation. Regardless of substantiation rates, multiple studies have supplied convergent findings from state and national datasets (e.g., LONGSCAN, National Studies on Child and Adolescent Well-Being) demonstrating that children with substantiated and unsubstantiated cases are at similar risk for a range of negative behavioral and developmental outcomes (Hussey et al. 2005). For this reason, many empirical investigations (e.g., Fang et al. 2012) have used “any report” in addition to or in place of “substantiated reports” as a measure of maltreatment in official records. Another factor that impacts the assessment of child maltreatment is the persisting problem of racial and ethnic disproportionality and disparity in the child welfare system. A considerable amount of research has documented the overrepresentation of racial and ethnic minority youth in the child welfare system. In 2017, for example,

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American Indian/Alaskan Native children experienced the highest rates of child maltreatment (14.3 per 1,000), followed by Black children (13.9 per 1,000) and multiracial children (11.3 per 1,000), as compared to 8.1 per 1,000 children for the general population (USDHHS 2019). Poverty, lower parental education, parental unemployment, single-parent status, as well as other social drivers of health contribute substantially to these differential rates of maltreatment (Putnam-Hornstein et al. 2013), but they do not tell the whole story. It is clear that racial bias, discrimination, and structural racism all play a part as the racial disparities that children of color encounter at every point in the child welfare continuum (from assessment to substantiation) and are equally as alarming. Black children are more likely to be removed from the home, spend longer time in foster care, and have a case that has been substantiated; they are also more likely to experience parental termination, and are less likely to be reunited with their families or adopted when compared to other racial groups (Child Welfare Information Gateway 2016). The plight for young black males further illustrates the pernicious nature of these disparities as they are more likely to age out of care, have more placement moves, and are more likely to be placed in institutional settings when compared to the general population of same-aged peers (Miller et al. 2012). Efforts to remediate both disproportionality and disparity in the child welfare system are underway and include cultural competence training; recruitment and retention of a diverse workforce; implementation of a range of prevention and early intervention programs (inhome services); revision and review of agency policies, in addition to state and federal legislation; support of community partnerships and initiatives; and development of equity metrics and monitoring systems.

Consequences of Child Maltreatment Introduction to Child Maltreatment Research Notwithstanding the definitional and assessment barriers discussed above, the sequelae of child abuse and neglect have been well documented in the literature. Adverse consequences for children’s development have been identified across multiple domains, including psychological, behavioral, and physical health. For many children, these effects extend far beyond childhood into adolescence and may persist into adulthood. The nature and severity of symptoms vary from child to child such that some will be asymptomatic or demonstrate resilience (Masten 2011), whereas others will be on the other end of the continuum, evincing severe distress that meets diagnostic criteria for one or more mental disorders (e.g., Kaplan et al. 1998; Widom et al. 2007). The pathways or mechanisms that link child abuse and neglect to the outcomes discussed below, as well as the context in which the outcomes manifest, are rooted in the study of developmental psychopathology (Cicchetti and Toth 2005). Developmental psychopathology has guided the study of the relative contributions of risk and protective factors of child maltreatment to myriad outcomes. This approach

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acknowledges that the processes involved in the development of psychopathology are complex, and that after exposure to child maltreatment, outcomes are multiply determined by characteristics of the individual, caregivers and family, and neighborhood and community, in addition to their interactions over time (Masten 2006). By virtue of its interdisciplinary, multilevel nature, the developmental psychopathology approach requires that multiple domains of development are investigated, including genetic, neurobiological, cognitive, linguistic, socioemotional processes (Cicchetti and Toth 2005). For the purpose of this chapter, psychological, behavioral, and physical health domains will be examined.

Psychological Outcomes Substantial evidence documents the deleterious impact of child maltreatment and other victimization experiences on internalizing and externalizing disorders. Internalizing disorders reviewed include depression, anxiety, and posttraumatic stress, while externalizing disorders include oppositional defiant disorder, conduct disorder, and other high-risk behaviors (i.e., substance use, suicidal thoughts and behaviors). Findings from clinical and community samples have illustrated that child maltreatment represents one of the strongest risk factors for developing depression and anxiety, such that abuse, neglect, and other adversities account for up to one-third of the risk for mood and anxiety disorders (e.g., Green et al. 2010; Widom et al. 2007). These effects tend to differ by gender as maltreatment has been found to convey greater risk for the development of internalizing symptoms in females than males (Lansford et al. 2002). Furthermore, there is increasing evidence that different types of maltreatment are associated with differential internalizing sequelae; nonetheless, focusing on one type of abuse may lead to spurious conclusions given the cooccurrence of maltreatment types. In a meta-analysis conducted by Li et al. (2016), individuals with any type of childhood maltreatment (i.e., physical abuse, sexual abuse, neglect) compared to those without a maltreatment history were 2.0 times more likely to have a depressive disorder and 2.7 times more likely to have an anxiety disorder in adulthood. With respect to specific types of abuse, individuals exposed to neglect, physical abuse, and sexual abuse were 1.8, 2.0, and 2.7 times more likely to develop depression or anxiety in adulthood, respectively (Li et al. 2016). Isolating depressive symptomatology, children exposed to maltreatment have a moderately increased risk of developing depression in adolescence and young adulthood, with adjusted odds ratios ranging from 1.51 (Widom et al. 2007) to 3.15 (Brown et al. 1999). There is also a relatively robust effect of repeated or chronic maltreatment on depressive symptoms (Ethier et al. 2004). Empirical evidence also suggests that maltreated children are at an elevated risk for both posttraumatic stress symptoms and a diagnosis of Posttraumatic Stress Disorder (PTSD; Kearney et al. 2010). PTSD includes an array of reactions, including persistent re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the event, negative alterations in thoughts and mood, and altered arousal and reactivity (American Psychiatric Association 2013). These reactions

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may be expressed differently depending on the type of maltreatment experienced, its severity and duration, the age of the child, and the ecological context in which the abuse or neglect occurred. For example, young children may exhibit their distress in terms of increased fears/fearfulness, sleep difficulties, re-enactment through play, and behavioral regression (Kearney et al. 2010). In contrast, adolescents may be more likely to express anger, mood swings, and reactivity, often experiencing suicidal ideation, risk-taking behaviors, and/or using substances. PTSD has been found to be especially likely after maltreatment experiences involving sexual and physical abuse, prior experiences of abuse or neglect, cognitive vulnerabilities (e.g., perceived ongoing threat, feelings of guilt, or victimization), and neurobiological changes (e.g., dysregulation of the hypothalamic-pituitary-adrenal axis) (Kearney et al. 2010). Regarding neurobiological changes, experiences of child maltreatment have been found to lead to dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, which is responsible for releasing glucocorticoids to enhance stress coping (Kearney et al. 2010). Maladaptive HPA axis functioning may involve failure to activate when necessary, activation when unnecessary, or failure to end glucocorticoid release when necessary (see Kearney et al. 2010 for an excellent review of HPA axis dysregulation). In addition to chemical changes, PTSD has been linked to adverse brain development and/or abnormalities including smaller intracranial volumes, cerebral volumes, midsagittal corpus callosum areas, and larger lateral ventricles (De Bellis et al. 1999). These changes may lead to difficulty with self-regulation and, thus, contribute to adoption of high-risk behaviors later in life.

Behavioral Outcomes Child maltreatment has also been linked to numerous externalizing behavior problems that fit into the general categories of aggressive acting out and high-risk behaviors. This is true of both broadband aggressive symptoms (Dodge et al. 1995), as well as specific diagnoses such as oppositional defiant and conduct disorders (Caspi et al. 2002; Kaplan et al. 1998). Empirical evidence suggests that physical abuse has a particularly robust association with externalizing behaviors (Turner et al. 2006), although early exposure to neglect is also associated with later externalizing behaviors (MacKenzie et al. 2011). Moreover, children who experience physical abuse before age five are four times more likely than non-abused children to display externalizing conduct problems in elementary school (Dodge et al. 1995). Focusing on specific mental health disorders, adolescents with substantiated physical abuse have six times the odds of meeting criteria for oppositional defiant or conduct disorder compared with adolescents without physical abuse histories (Kaplan et al. 1998). While oppositional defiant disorder is characterized by persistent patterns of angry or irritable mood and argumentative and defiant behavior, conduct disorder captures behaviors that violate social norms, including aggression or cruelty towards humans or animals, intentionally destroying property, and lying or

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theft (American Psychiatric Association 2013). Focusing on examinations of conduct disorder, large epidemiological studies have established a link between maltreatment experiences and genetic vulnerability that dramatically increases the risk of conduct disorder in youth with both risk factors (Caspi et al. 2002). In addition to aggressive acting out, child maltreatment has also been associated with increased rates of high-risk behaviors in childhood, adolescence, and young adulthood, including alcohol and substance use, as well as suicidal ideation and attempts. Much of the research on the link between child maltreatment and substance use has focused on the early initiation of alcohol and substance use given that early initiation may serve as a mechanism for later substance use in adulthood (Lansford et al. 2010). Both physical and sexual abuse predict experimentation with and use of alcohol and illegal substances earlier in life (Ompad et al. 2005). For example, the younger the age of sexual abuse onset, the younger the age of drug use initiation, including marijuana, alcohol, inhalants, non-injection drugs (i.e., heroin, crack, cocaine, methamphetamines), and injection drugs (Ompad et al. 2005). Suicidal behavior, which includes both suicidal ideation and attempts, is also strongly associated with a history of child maltreatment. Links between maltreatment and suicidal behavior are evident at quite a young age (Thompson et al. 2005) and persist well into adolescence (Thompson et al. 2012). In one salient example of the developmental specificity of abuse, children exposed to sexual abuse during early childhood had a 146% increase in the odds of suicidal ideation relative to those maltreated during adolescence (Dunn et al. 2013). Regarding trauma types, exposure to physical abuse (Dunn et al. 2013), sexual abuse (Dunn et al. 2013), and psychological abuse (Thompson et al. 2012) are particularly associated with suicidal ideation. In fact, physical and sexual abuse are associated with more than double and triple the likelihood of suicidal ideation, respectively. It follows that suicidal behavior is also more common among individuals with a history of abuse and neglect, with research indicating that the odds of demonstrating suicidal behavior is 2.4 times higher in individuals exposed to childhood sexual abuse, even after controlling for genetic risk and early family environment (Devries et al. 2014). Taken together, the consequences of child maltreatment can be life-threatening, underscoring the pressing need for timely prevention and intervention strategies.

Physical Health Outcomes For some children who have experienced abuse, the consequences of maltreatment manifest most conspicuously in the form of physical injury. Some abuse experiences may not leave a physical mark on a child, while others may cause permanent disability, disfigurement, or death (Leeb et al. 2011). With respect to physical abuse, common injuries include fractures, bruises, and burns, whereas for infants and toddlers, physically abusive head trauma can result in injury to the skull or intracranial contents from impact or violent shaking, with serious sequela such as skull fracture, retinal hemorrhaging, subdural hematoma, permanent neurologic disability, intellectual disability, cortical blindness, and seizure disorders (American

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Academy of Pediatrics 2001). Sexual abuse may involve genital, anal, or oral injury; sexually transmitted infections (Kelly and Koh 2006); and pregnancy in postpubertal girls. Moreover, health consequences of neglect encompass failure to thrive, unmanaged obesity, vitamin deficiencies, untreated medical conditions, and injuries such as burns or overdose/poisoning resulting from lack of supervision (Hobbs and Bilo 2009). In addition to proximal physical outcomes, youth with histories of child maltreatment report elevated rates of chronic illness, in that up to 87% of children entering foster care have at least one chronic illness, such as infectious dermatitis, asthma, dental caries, and anemia, ultimately resulting in greater medical costs (Leslie et al. 2005). Relatedly, compared to youth with no history of abuse or neglect, children and adolescents affected by maltreatment demonstrate greater healthcare utilization costs (Florence et al. 2013) and more frequent hospital, primary care, and specialty healthcare visits (Bonomi et al. 2008). Looking beyond health records, adolescents with maltreatment histories self-report lower ratings of their own overall health indicating prominent effects on both subjective and objective health measures (Hussey et al. 2006). In adulthood, studies of maltreatment and physical health often utilize the Adverse Childhood Experiences (ACEs) Study (Felitti et al. 1998), which operationalized early adversity using ten experiences that may occur within a household. The original inventory asked adults to retrospectively report on their experiences of childhood physical, emotional, and sexual abuse, as well as physical and medical neglect and exposure to domestic violence. It also inquired about household dysfunction in childhood, including parental substance abuse, mental illness, incarceration, separation, and divorce. Results from the ACEs Study revealed a graded, dose-response relationship between the cumulative number of selfreported ACEs and negative health outcomes in adulthood. Compared to individuals with one ACE, those with four or more ACEs were more likely to experience sexually transmitted diseases, heart disease, diabetes, and early death, among other outcomes. Unfortunately, there is currently no scientific consensus about which of the ten adverse childhood experiences are most important to short-term health outcomes in childhood or adolescence. Much like the ACEs Study, adult health outcomes after childhood maltreatment are often examined retrospectively or using cross-sectional studies – the limitations of which are well established. Overall, adults who report histories of abuse have high rates of primary care and hospital visits (Hulme 2000) and high annual healthcare costs, particularly among women (Tang et al. 2006). Adult health outcomes associated with childhood maltreatment include, but are not limited to functional pain disorders, migraines, gynecological pain, ischemic heart disease, irritable bowel syndrome, cancer, chronic bronchitis, skeletal fractures, as well as overall ratings of poor physical health. There is increasing evidence that these outcomes may be related to the type of child abuse or neglect experienced in childhood. For example, Springer et al. (2007) discovered that the odds of having allergies, arthritis/rheumatism, asthma, bronchitis/emphysema, circulation problems, high blood pressure, heart troubles, liver troubles, and ulcers are 34% to 167% higher in adults with

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histories of physical abuse (compared to those without physical abuse histories), controlling for demographic characteristics (Springer et al. 2007). Many studies have shown a clear relation between childhood maltreatment and adult health outcomes, but it must be underscored that the development of these negative consequences does not occur in a vacuum. Rather, abuse and its outcomes unfold within a multi-level topography of risk and protective factors. These factors interact in complex ways to affect youth and adult health, necessitating longitudinal investigations of mental and physical health to capture pathways and processes of development (Masten 2006).

Resilience As described above, exposure to child maltreatment poses threats to children and adolescents’ psychological, behavioral, and physical health. However, there is also compelling evidence that many children who experience abuse and neglect demonstrate resilience after adversity, that is, “the capacity of a dynamic system to withstand or recover from significant challenges that threaten its stability, viability, or development” (Masten 2011, p. 494). Resilience is a dynamic process, not a personality trait, meaning that a child can exhibit resilient outcomes in one developmental stage but demonstrate negative outcomes at a later time (Luthar et al. 2000). Consistent with the developmental psychopathology framework that asserts the importance of investigating multiple domains of development, youth who demonstrate resilience may manifest competence in one or more domains of functioning, such as maintained academic, socioemotional, or behavioral functioning (i.e., multidimensionality; Luthar et al. 2000). For example, after maltreatment, children may continue to earn good grades in school, establish and maintain close relationships with others, and avoid high-risk behaviors, such as using alcohol or drugs or fighting with peers. There are fundamental but common and ordinary adaptive systems that play a crucial role in resilience, including close relationships with competent and caring adults in the family and community, cognitive and selfregulation skills, caregiver-child relationships, and the motivation for learning and engaging in the environment (Masten 2011). These factors are often defined as protective factors and have been investigated at the levels of the individual, family, and social environment.

Mechanisms of Effects While a corpus of empirical evidence indicates that child maltreatment adversely impacts development across multiple domains, less is known about how it exerts these effects. Given the associations between child maltreatment and negative mental and physical health outcomes later in life, understanding the pathways or mechanisms through which these relations occur is critical for prevention and treatment efforts. Several biological, behavioral, and social/interpersonal pathways

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have been examined in the research. For example, high levels of stress experienced over extended periods of time can damage areas of the brain and suppress the body’s immune response. Specifically, there is an increased risk of marked dysregulation of the HPA axis and sympathetic nervous system that can persist long after initial abuse. Disruptions in these neurohormonal systems have been shown to impact the human immune system, leading to chronic inflammation and thereby increasing an individual’s susceptibility to illness and disease (De Bellis et al. 1999). Additionally, children and adolescents who have experienced abuse or neglect are more likely to engage in unhealthy behaviors associated with poor health outcomes, such as problematic alcohol or drug use and risky sexual behaviors to minimize emotional pain and/or recurrent memories of maltreatment experiences (Anda et al. 1999). Socially, children with a history of abuse are more likely to experience difficulties in interpersonal relationships and report lower levels of social support which, in turn, have been linked to an increased risk of mortality and poor health outcomes (Smith and Christakis 2008). Finally, maltreatment may disrupt many normal developmental processes, such as the development of self-concept, interpersonal relationships, or self-regulation of affect or arousal, potentially resulting in. increased vulnerability to subsequent trauma.

Economic Costs of Child Maltreatment Looking beyond individual outcomes, child maltreatment’s consequences can also be examined from a societal or economic perspective. Economic estimates help increase public awareness of the high prevalence child maltreatment, place child maltreatment in the context of other public health concerns, and may be used in the economic evaluation of interventions to reduce or prevent child abuse and neglect (Fang et al. 2012). In 2012, Fang and colleagues measured the costs of child maltreatment by investigating the lifetime economic burden of child maltreatment in one year. For nonfatal cases, calculations included healthcare costs (i.e., short- and long-term physical and mental health), productivity losses, child welfare costs, criminal justice costs, and special education costs. For fatal cases, estimations included medical costs and productivity losses. Results revealed the estimated lifetime cost per victim of nonfatal and fatal child maltreatment to be $210,000 and $1.3 million, respectively, and the annual economic burden to be $124 billion. The economic cost of child maltreatment was updated in 2018, with researchers implementing a societal cost methodology (Peterson et al. 2018). This methodology assesses all measurable costs attributable to the morbidity and mortality of given health conditions, including tangible costs to particular payers (e.g., health system, employer) and intangible costs such as the pain and suffering experienced by an affected individual. These adjustments increased the estimated per-victim cost of nonfatal and fatal child maltreatment to $831,000 and $16.6 million, respectively. The annual economic burden was calculated to be $428 billion using rates of substantiated maltreatment and $2 trillion using rates of investigated maltreatment cases.

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Risk Factors for and the Context of Child Maltreatment One of the largest obstacles to understanding the distinct impact of child maltreatment involves the challenge of disentangling its effects from those of its larger context. It is undeniable that there are correlates of maltreatment at the caregiver, family, and neighborhood levels in that child abuse and neglect are usually not the only negative or adverse event a child experiences. Therefore, investigating the degree to which a particular negative outcome results from child maltreatment, rather than other risk factors – including caregiver depression and substance use, intimate partner or domestic violence, family hardship, or neighborhood dysfunction – remains difficult. Acknowledging that the aforementioned risk factors rarely occur in isolation, there is evidence to suggest that the presence or constellation of multiple risk factors may increase the likelihood of child maltreatment. It is critical to recognize, however, that these factors simply describe the context of elevated risk and causal pathways have not been identified between these factors and child maltreatment. Thus, the complex interactions among multiple risk factors, particularly in conjunction with resilience or protective factors, are not clearly understood. A full review of the contextual factors that are associated with the etiology of maltreatment is beyond the scope of this chapter. Nevertheless, an overview is provided with factors that must be considered, ranging from the context of the caregiver or family to the neighborhood or community.

Parental and Caregiver Risk Factors Empirical evidence indicates that parental mental health issues (e.g., depression, schizophrenia, and substance abuse) increase the risk for the perpetration of child maltreatment. Studies have demonstrated that mothers experiencing depression may be more pessimistic, irritable, and less responsive to their children’s needs relative to mothers without depression. As a result, children of parents with diagnoses of major depression or schizophrenia are two times more likely to experience abuse than children of parents without mental illness, with risk increasing to six times more likely when parents engage in antisocial behaviors (Walsh et al. 2002). Children of mothers with mental illness also have an increased likelihood of foster care placement, as mothers with serious mental illness (i.e., schizophrenia or a major affective disorder) have been found to be almost three times more likely to have their child removed from their care than mothers without serious mental illness (Park et al. 2006). Along with serious mental illness, substance abuse is also considered to be a risk factor for the perpetration and recurrence of child maltreatment. Results from a longitudinal study of 224 children from families with low socioeconomic status revealed that mothers who reported that they had used drugs in the past were found to be 1.7 times more likely to have an associated report to child protective services for abuse or neglect compared with mothers who had never used drugs. Regarding recurrence of child maltreatment, maternal drug use was found to be one of five risk factors that significantly predicted a subsequent report to child protective services (Dubowitz et al. 2011).

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Familial Risk Factors At the level of the family, maltreatment is intricately interwoven with family dysfunction and violence, as well as family income and structure. In a meta-analysis conducted by Stith et al. (2009), investigators examined a variety of family characteristics related to child maltreatment by type of child abuse and neglect (Stith et al. 2009). Physical abuse was found to be most strongly associated with family conflict, family cohesion, and spousal violence, while neglect was found to be moderately associated with family size. Specific investigations of spousal or intimate partner violence reveal that roughly half of families with official maltreatment reports have at least some indication of intimate partner violence (English et al. 2005). Finally, for children in homes reporting intimate partner violence compared with those without such violence, the odds of experiencing maltreatment range from two to ten times higher, referring to neglect and emotional abuse, respectively (Zolotor et al. 2007). Another familial risk factor of interest is social isolation, with research indicating that the difference between neighborhoods with high and low child maltreatment rates is more intimately related to social integration (or disintegration) than social impoverishment (Deccio et al. 1994). Social isolation not only occurs informally but also through more formal systems of support like disconnection from peer groups, neighborhood organizations, or other community resources. Residential mobility may also lead to social isolation with experts suggesting that the rapid turnover of residents within neighborhoods results in the breakdown in the social fabric of those areas (Aisenberg and Herenkohl 2008). Over time, tears in the social and relational fabric of neighborhoods leaves caregivers disconnected from other community members who may have previously offered assistance in childrearing or provided other supports. Finally, both family income and family structure (e.g., density, single-parent household, extended networks) have been linked to maltreatment and poor child outcomes. Much recent research suggests that family economic hardship, rather than family income, is a particularly salient risk factor for child maltreatment. Family hardship occurs when a household has insufficient income to meet basic necessities, including lack of resources for food, housing, and/or utilities in the last six months (Lefebvre et al. 2017). In this vein, families facing economic hardship are almost two times more likely to be involved in substantiated maltreatment investigations compared to children whose families are not affected by insufficient income. Family size is also positively related to child abuse and neglect, such that children of larger families are at higher risk of maltreatment (Sedlak et al. 2010). However, other factors such as cohesion among family members and family conflict are even more strongly related in such cases (Stith et al. 2009).

Neighborhood Risk Factors Multiple neighborhood-level risk factors are important to consider in maltreatment risk, including neighborhood safety and cohesion. According to Coulton and

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Korbin (2007), “Neighborhoods are more than collections of individuals or locations for populations; they also include space, physical structures, social networks, formal and informal organizations, businesses, systems of exchange and governance, and so forth” (p. 350). Therefore, it is likely that myriad facets of neighborhood structures and networks are entwined with maltreatment risk. There is considerable support to suggest that neighborhood economic distress or disadvantage is associated with elevated rates of child maltreatment, in addition to variables related to increased child-care burden, vacant housing, lower female labor force participation, overcrowding, and per capita density of alcohol outlets (Coulton et al. 2007). In fact, the per capita number of off-premise alcohol outlets (e.g., liquor, grocery, convenience stores) is positively associated with rates of physical abuse, while the density of bars is significantly associated with neglect (Freisthler et al. 2014). Unfortunately, these neighborhood characteristics provide little information about the processes through which neighborhood characteristics affect child maltreatment. A considerable amount of information is now available on the parental, familial, and neighborhood risk factors related to child maltreatment. Of note, it is critical to recognize that the aforementioned factors delineate elevated risk, while none has demonstrated a causal relationship with child abuse and neglect. Regardless, advancing the study of risk factors, as well as protective processes, will build capacity for programs and policies to prevent and address child abuse and neglect from multiple ecological levels.

Limitations and Future Considerations in Child Maltreatment Research and Practice Limitations in Child Maltreatment Research This chapter has reviewed the current topography of child maltreatment research, spanning from definitional considerations and the spectrum of its effects and consequences to the constellation of risk factors that are associated with abuse and neglect exposure. Although a comprehensive future research agenda is beyond the scope of this chapter, research must be directed at the most consequential knowledge gaps given the severity of this public health problem. The Committee on Child Maltreatment Research, Policy, and Practice for the Next Decade crafted an impressive national research agenda for the Administration for Children and Families to advance the study of child abuse and neglect (IOM and NCR 2014). Please refer to the Committee’s recommendations related to the causes and consequences of maltreatment, services research in complex systems, and child abuse and neglect policy. These recommendations are supported by three guiding principles to further investigate the roles of cultural, social, and ecological processes; utilize multiple levels of analysis across disciples, methods, and sectors; and build upon the extant

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child abuse research and knowledge base. Guidance regarding definitional considerations, epidemiological surveillance, and multi-level research designs within longitudinal data sets is reviewed below. Akin to other disciplines of science, in order to study any phenomenon, there must be general agreement on what is being studied and how often it occurs. As noted previously, a predominant barrier to the assessment, prevention, and treatment of child maltreatment is the lack of clarity in definitions. Similar concerns arise for research purposes as, for example, child protective service agencies define maltreatment differently depending on the jurisdiction. While the standardization of definitions is aspirational, the Institute of Medicine and National Research Council argue that uniform definitions are not feasible nor recommended. Instead, these academies argue that because child abuse and neglect encapsulate a diverse set of behaviors with implications relevant to multiple domains of research, definitions must be robust yet flexible enough to afford investigation across systems (IOM and NCR 2014). A set of uniform definitions, in combination with concretized methodologies for use in research, could support the development of a population-based, epidemiological surveillance system for child maltreatment (IOM and NCR 2014). Epidemiological surveillance would result in more accurate incidence and prevalence rates, the identification of populations at greatest risk, and a detailed study of neighborhood, community, and societal risk factors to guide prevention and treatment efforts. Paralleling the developmental psychopathology approach, child maltreatment research also necessitates a multilevel framework bridging disciplines, utilizing quantitative and qualitative methodologies, and examining numerous levels of analysis. Future research endeavors will require the collaboration of professionals across multiple service systems (e.g., child welfare, juvenile justice, mental health, healthcare), as well as orchestrated efforts to begin and maintain prospective longitudinal studies. Longitudinal studies beginning before birth allow researchers to determine the temporal order of risk factors; adjust for individual, familial, and neighborhood correlates as they arise; and minimize the reliance on retrospective or cross-sectional investigations. Fortunately, a handful of longitudinal studies currently exist as templates for future research efforts. One particularly excellent example is the Longitudinal Studies in Child Abuse (LONGSCAN), a consortium of research studies initiated in 1990 from the National Center on Child Abuse and Neglect through a coordinating center at the University of North Carolina and five satellite sites (Runyan et al. 1998). Although each study was developed to stand and operate alone, sites use common assessment measures, similar data collection methods and schedules, and pooled analyses to permit a comprehensive exploration of many critical issues in child abuse and neglect. The combined sample is of sufficient size for unprecedented statistical power and flexibility (N ¼ 1,354), with the capability to replicate and extend findings across a variety of ethnic, social, and economic subgroups. Investigations like LONGSCAN also have an enhanced ability to isolate and examine the roles of race, ethnicity, and culture, while modeling an increased focus on underserved and under-researched populations.

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Future Considerations in Child Maltreatment Research and Practice Fortunately, solutions do exist that either minimize the impact of or in some cases prevent child abuse and neglect entirely. Indeed, a variety of prevention and treatment programs are implemented through various child- and family-service system agencies. Reviews of child maltreatment prevention efforts have concluded that many communities have access to both primary and secondary preventive interventions to reduce the risk for child abuse or neglect within families experiencing difficulties. Frustratingly, the availability and dissemination of these programs are uneven across communities, leaving many of the most vulnerable children and families without adequate or culturally sensitive services. To date, a large breadth of evidence-based child abuse and neglect prevention programs are funded and implemented at the community level to address the needs of at-risk children and families. Strategies such as early home visiting targeting pregnant women and parents with newborn infants are well researched and have evidenced improvements in the reduction of risk factors commonly associated with maltreatment, in addition to maltreatment itself. Findings from Avellar and Supplee’s (2013) comprehensive review of home visiting programs concluded that multiple models have demonstrated reductions in child maltreatment, including Nurse-Family Partnership, Early Head Start, and Healthy Families America, among others. Moreover, most models provide education about child development, promote positive parent-child interaction, and improve child functioning. The substantial burden of child maltreatment is unlikely to be ameliorated by siloed and system-specific efforts. As such, it is imperative to cultivate a multipronged and collaborative approach to prevention, early intervention, and treatment that reaches across disciplines and service systems. One innovative collaborative endeavor that has had significant impact on practice, research, and policy in the fields of child maltreatment and traumatic stress is the National Child Traumatic Stress Network (NCTSN). Established by Congressional mandate in 2001, NCTSN is funded through the Substance Abuse and Mental Health Services Administration. The mission of the NCTSN is to use state-of-the-art, empirically supported interventions to raise the standard of mental healthcare and improve access to services for youth with trauma exposure, their families, and communities throughout the United States. The NCTSN is coordinated by the UCLA-Duke University National Center for Child Traumatic Stress and has grown to over 100 currently funded centers and over 150 affiliate (formerly funded) centers within hospitals, universities, and community-based programs. The centers include both academic and community practice centers, therefore merging expertise and knowledge in areas of child development, traumatic stress, clinical interventions, terrorism and disaster, and cultural and familial perspectives across multiple services systems, including schools, child welfare, juvenile justice, and law enforcement. To accomplish its mission, NCTSN grantees and affiliate sites work to provide clinical services, develop and disseminate new interventions and resource materials, offer education and training programs, collaborate with established systems of care, engage in data collection and evaluation, and inform public policy and awareness

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efforts. A critical component of the data collection initiative is the unprecedented collection of direct-service client data and outcomes in the form of the NCTSN Core Data Set with trauma history profiles and array of assessment findings from 14,088 children and adolescents. The NCTSN also supports the effective dissemination, implementation, and adaptation of evidence-based practices and treatments through the training and implementation program. Multisite training and implementation efforts have been conducted for selected trauma-focused treatments, including Trauma-Focused Cognitive-Behavioral Therapy, Parent Child Interaction Therapy, and Structured Psychotherapy for Adolescents Responding to Chronic Stress. Currently, the field of child maltreatment is beginning to move beyond the development of efficacious and effective prevention and treatment models to consider evidencebased implementation strategies to adopt and sustain these models in a variety of community settings. Such strategies promote the tailoring or adapting of treatments for distinct populations or groups so as to ensure cultural and linguistic fit, as well as social and ecological validity and practical application.

Summary and Conclusion Child maltreatment is a significant and devastating public health problem, as it not only exerts its effects on children and adolescents but also their families, communities, and society at large. These far-reaching consequences necessitate a multipronged and multi-disciplinary approach to research, practice, and policy grounded in the complex systems in which child abuse and neglect occur. Considerable efforts should be made in addressing the standardization definitions, enhancing epidemiological surveillance of the incidence and prevalence of child maltreatment, and supporting the maintenance and establishment of longitudinal data sets with multilevel research designs. Consequently, larger investments in child maltreatment research and practice are required to improve the nation’s mental and physical health and to create safe, stable, and nurturing environments for our most vulnerable assets – our children.

Key Points • Child maltreatment is comprised of both child abuse and neglect, with child abuse referring to acts of commission such as sexual abuse, physical abuse, and psychological abuse; whereas neglect describes acts of omission, including the failure to provide and supervise. • A barrier to the assessment, prevention, and treatment of child maltreatment is the lack of clarity in defining and operationalizing primary and associated maltreatment terms, as well as considering other conceptual aspects (e.g., severity, age of onset, duration, and perpetrator type). • The pathways and mechanisms that link child abuse and neglect to adverse outcomes are rooted in the study of developmental psychology, which

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acknowledges the multilevel interplay of both risk and protective factors across developmental domains (e.g., genetic, neurobiological, cognitive, linguistic, socioemotional domains). • Investigating the degree to which particular negative outcomes result from child maltreatment, rather than other risk factors – such as caregiver depression and substance use, domestic violence, family hardship, or neighborhood dysfunction – remains difficult. • To improve prevention and treatment efforts, a population-based, epidemiological surveillance system for child maltreatment is recommended to provide more accurate incidence and prevalence rates, the identification of populations at greatest risk, and a detailed study of neighborhood, community, and societal risk factors. • The substantial burden of child maltreatment is unlikely to be addressed or ameliorated by siloed and system-specific efforts; rather, a multipronged and collaborative approach to prevention, early intervention, and treatment is needed across disciplines and service systems.

Cross-References ▶ Adverse Childhood Experiences: Past, Present, and Future ▶ Psychological Maltreatment of Children: Influence Across Development ▶ Sexual Abuse of Children ▶ The Child Welfare System: Problems, Controversies, and Future Directions ▶ The Nature of Neglect and Its Consequences

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Section III Physical Abuse of Children and Adolescents Ernestine Briggs, Theodore P. Cross, Amy Russell, Michelle Clayton, Javonda Williams, Stacie Schrieffer LeBlanc, Heather J. Risser, Viola Vaughan-Eden, and Victor I. Vieth

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Defining Physical Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Connections to Other Forms of Interpersonal Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Risk and Protective Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intrapersonal Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . External Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Protective Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevention Initiatives and Intervention Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Public Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Physical child abuse is a global public health concern associated with wideranging adverse outcomes for children and incurring substantial costs for society. Because of variability in defining and reporting physical child abuse worldwide, prevalence rates vary widely, but the consensus opinion is that physical abuse is both pervasive and inadequately tracked through official mechanisms. Nearly all physical abuse of children is perpetrated by parents or alternative caregivers, with This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. C. M. Rodriguez (*) · D. F. Pu University of Alabama at Birmingham, Birmingham, AL, USA e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_183

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whom the child has some attachment. Parents who physically abuse their children are also likely to be involved in other forms of interpersonal violence such as intimate partner violence. A range of factors appears to contribute to parents’ risk of engaging in physical abuse. Experiences from their personal background can increase parents’ abuse risk, but the bulk of literature has implicated more proximal risks, including intrapersonal affective and cognitive factors as well as external and societal influences. Less research has explored protective factors that could reduce parents’ physically abusive behaviors. Nonetheless, prevention and intervention programs strive to mitigate risks and cultivate potential protective qualities in an effort to avert physical abuse, with modest success. Important advances are still needed to improve identification of parents engaged in abuse, and more importantly, those at risk in order to proactively prevent physical abuse. Further, progress is needed to identify robust risk factors and, most critically, protective factors. Some countries have adopted policies to identify child abuse, but global investment remains greater in responding to abuse rather than preventing it, despite the cost-effectiveness of prevention. Keywords

Child abuse · Child maltreatment · Physical discipline · Intimate partner violence · Cross-cultural · Cycle of violence · Resilience · Abuse prevention · Public policy

Introduction Physical child abuse has long been recognized as one of the core adverse childhood experiences, which are known to compromise children’s short-term and long-term physical and mental health outcomes. Worldwide, countries expend substantial resources in responding to the sequelae of child maltreatment, within the physical and mental healthcare system and the criminal justice system. Conservative estimates suggest the costs of violence against children amount to 2–5% of global GDP (Pereznieto et al. 2014). In a single year, this translates to at least $124 billion in the USA and as much as $7 trillion globally (Pereznieto et al. 2014). Undoubtedly, child maltreatment presents a substantial public health concern. To address this concern, more progress is needed to understand the parents who engage in physical child abuse – the focus of this chapter.

Defining Physical Abuse As with many mental and physical health problems, the first hurdle to addressing physical child abuse begins with defining which actions constitute physical abuse – a continuing source of international debate. For example, the official legal definition of physical child abuse in the USA refers to the use of physical force “that caused or

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could have caused physical injury to a child” (US Department of Health and Human Services [DHHS] 2018, p. 107). States in the USA differ somewhat in what is required to designate an incident as physical abuse, but most child protective services across the country substantiate physical abuse if pain or physical marks remain evident in the child at least 48 h after the incident. Despite the language in the legal definition, most jurisdictions do not pursue cases that merely “could” have resulted in injury. Implicit in this definition is that physical abuse is an act of commission, implying the behavior was intentional. Thus, the USA congressionally mandated surveillance report that produced the fourth National Incidence Study of Child Abuse and Neglect (NIS-4) expressly required cases of physical abuse be counted only if they arose from avoidable – not accidental – actions (Sedlak et al. 2010). Similar reference to physical harm arising from deliberate physical force appears in the legal definitions utilized in other countries (e.g., Canada, UK, Australia) although many countries do not formally define or track any type of child maltreatment (World Health Organization [WHO] 2014), complicating crosscultural comparisons. Intentionality remains one of the more complex elements in the definition of physical child abuse. Parents are typically invested in their children’s welfare, including those who have physically abused their children, because the vast majority do not plan to physically abuse. The complexity therefore arises because of parents’ use of physical discipline. In physical discipline, the deliberate use of physical force is applied to deter children’s misbehavior expressly intended to inflict pain but not intended to injure. Thus, in the USA and several other countries, the primary distinction between physical abuse and physical discipline centers on the result of using that physical force–physical injury that persists for a period of time. The vast majority of physical abuse transpires during an episode of a caregiver’s intentional administration of physical discipline, particularly when physical punishment escalates and becomes more intense or excessive. Indeed, meta-analyses have documented strong effect sizes linking parents’ physical punishment use and physical child abuse (d ¼ 0.64), as well as adverse outcomes from parents’ use of physical discipline (Gershoff and Grogan-Kaylor 2016). Therefore, physical discipline (in the USA along with several other countries) remains the only form of interpersonal physical aggression in which intentionally inflicting pain is socially acceptable (e.g., evident in high US public approval for spanking children; childtrends.org/indicators/attitudes-toward-spanking) as long as the harm is not apparent and persistent for days after the incident. In contrast to such norms in the USA, the World Health Organization adopts a more inclusive definition of physical child abuse. According to the WHO ( 2006), physical child abuse involves the intentional use of physical force that has a “high likelihood of resulting in. . .harm for the child’s health, survival, development, or dignity” (p. 10) – a definition that captures all forms of physical force and noticeably does not limit the consequences to physical injury. Similarly, the United Nations advocates for protecting children from any expression of physical or mental violence (UN Convention on the Rights of the Child, article 19, para. 1), despite the absence of outwardly visible signs of injury because of the inferred negative impact of any

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physical force on a child to their psychological well-being. Over 50 nations legally prohibit all forms of hitting children in the home, considering any use of nonaccidental physical force on a child as an expression of physical abuse, regardless of observable or persistent injury. Although all other UN member nations are parties to the Convention on the Rights of the Child, the USA is not, maintaining its more stringent definition of physical child abuse, which serves to exclude physical punishment. The scope of the definition of physical child abuse has clear implications, fundamentally influencing research, estimates of prevalence, identification of perpetrators, clarification of risk and protective factors, and development of abuse prevention and intervention approaches.

Epidemiology Physical child abuse represents the second most prevalent form of child maltreatment, after neglect. Based on the official statistics of cases reported to child protective services in the USA, physical abuse is identified in about 18% of substantiated cases of child maltreatment (DHSS 2018), a proportion that has been relatively stable for the past decade. Therefore, approximately 125,000 US adults engaged in officially identified physical abuse in 2016 (DHHS 2018). Of the estimated 1750 children who died from maltreatment in the USA in 2016, over 44% involved physical abuse (DHSS 2018). Around the world, parents are reported to commit 56.5% of all child homicides, with parents from higher-income countries implicated in filicide at higher rates – over 64% of cases (Stöckl et al. 2017). Yet the preponderance of evidence consistently underscores that reported cases significantly underestimate the scope of child maltreatment (Sedlak et al. 2010). Using a system of surveying a range of observers who may not consistently officially report child abuse incidents (NIS-4), 4.4 out of 1000 US children were physically abused even when employing the most stringent standard of demonstrable harm (Sedlak et al. 2010) – representing nearly three times the rate reported to official child protective services. This surveillance system also suggests 26% of all maltreatment involved physical abuse with nearly 300,000 adults perpetrating physical child abuse (Sedlak et al. 2010). Moreover, physical child abuse typically occurs unwitnessed, in the privacy of the home. Using its less stringent definition, the WHO ( 2014) estimates that 25% of the world’s population report they were physically abused as children. Even in the USA, with its narrower definition, across 114 studies, the median reported lifetime prevalence of child physical abuse is 15.3% (see child maltreatment interactive site for WHO, apps.who.int/violence-info/child-maltreatment). A recent phone survey with a representative US sample indicated that 8.4% of children experienced physical child abuse sometime in their life, with 3.3% experiencing physical injury from just the most recent incident (Simon et al. 2018). Those findings are consistent with another US nationally representative sample using the Parent-Child Conflict Tactics Scale, in which parents self-reported their use of severe physical discipline tactics (e.g., use of an object, kicking, beating up) at a rate of 87 per 1000 (Straus et al. 1998).

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In other words, these estimates translate to a rate of between 3.3 and 8.7 children out of 100 rather than the 4.4 children out of 1000 estimated in the NIS-4 report (Sedlak et al. 2010) – all considerably higher than official reports of child abuse. The Parent-Child Conflict Tactics Scale has been administered in a variety of countries demonstrating high rates of hitting children with objects (9–74%) and beatings (0.1–28.5%) – estimates that indicate a median of 16% of children experienced harsh or potentially abusive discipline (Runyan et al. 2010). But parental self-report on such measures as the Parent-Child Conflict Tactics Scale relies on parents’ willingness to disclose what actual discipline practices they employ, including highly abusive approaches, which would be limited by social desirability responding. Collectively, these data highlight two important conclusions: physical violence toward children around the world is widespread, and physical child abuse is far more common than official legal systems track. Physical child abuse is almost entirely committed by parents or alternative caregivers (e.g., step-parents). For example, in the USA, biological parents accounted for 72% of physical abuse cases, with non-biological caregivers (e.g., step-parents, live-in partners, foster parents) accounting for an additional 19% (Sedlak et al. 2010). Parents who physically abuse children are only somewhat more likely to be maternal caregivers: in the USA, among biological parents, mothers constituted 56% of those who engaged in physical abuse, but among nonbiological caregivers who engaged in physical abuse, fathers are overrepresented (74%) (Sedlak et al. 2010). However, in other regions of the world, fathers may engage in more physical child abuse (as observed in China, Brazil, and Kuwait). Whether mothers versus fathers perpetrate more physical child abuse likely reflects cultural gender norms regarding which caregiver is considered to be the most appropriate disciplinarian. Males, however, appear to be more likely to engage in more injurious forms of physical abuse than mothers (Starling et al. 2007), evidently using more force. Notably, virtually all physical abuse of children is performed by an individual the child views as a parent figure with whom they are likely to have some degree of emotional attachment. Other than parent gender, younger parents are considered to be at greater risk to physically abuse than older parents (Black et al. 2001; Kim 2009; MacMillan et al. 2013), likely a reflection of the limited life experience and reduced resources that are available to adolescent and young adult parents. Limited resources also likely contribute to why physical abuse is more frequent among lower-income groups (DHHS 2018; Begle et al. 2010; Ben-David et al. 2015; Doidge et al. 2017; MacMillan et al. 2013; Sedlak et al. 2010). Unemployment rates are also higher among those who physically abuse their children (Doidge et al. 2017; Kim 2009; Sedlak et al. 2010). Rates of physical child abuse are lower in families with two biological parents (Simon et al. 2018) and highest among families with single biological parents with a live-in partner (Sedlak et al. 2010). With regard to race and ethnicity, in the USA, African-American and Hispanic parents are overrepresented (relative to their proportion in the general population) among officially reported cases of physical maltreatment (Sedlak et al. 2010) and in physical abuse reported in telephone surveys (cf. Simon et al. 2018). However, questions have been

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raised about whether such racial and ethnic disproportionality is largely a reflection of socioeconomic factors rather than race or ethnicity per se (see, e.g., PutnamHornstein et al. 2013). Altogether, a common thread through these demographic and background characteristics is that qualities that reflect parents’ reduced access to resources can detract from their parenting and increase their risk to physically abuse their children.

Connections to Other Forms of Interpersonal Violence Based on officially reported cases of child maltreatment in the USA, the most common form of substantiated polyvictimization involved physical abuse co-occurring with physical neglect – 5.2% of all maltreatment in 2016 (DHHS 2018). Given that neglect reflects acts of omission rather than acts of aggression, this low percentage of officially reported multiple maltreatment might lead one to conclude physical abuse does not overlap with other forms of aggression toward children. However, one examination of families involved in child protective services identified several areas of polyvictimization, with physical and emotional abuse co-occurring at 7.6% and combined physical and emotional abuse also co-occurring with neglect at 19.2% (Kim et al. 2017) – suggesting considerably more polyvictimization with physical abuse than officially reported. Some evidence does suggest parents’ use of harsh and physically abusive discipline tactics strongly relate to their use of psychologically abusive tactics (e.g., Rodriguez and Richardson 2007; Straus et al. 1998). Yet psychological abuse is routinely the most underreported form of child maltreatment (DHHS 2018). Indeed, the premise behind the WHO’s more inclusive definition of physical abuse as potentially harming a child’s dignity implies that any form of hitting by an adult caregiver with whom the child has an attachment is likely to incur psychological harm regardless of physical injury. Physical child abuse also frequently co-occurs with other expressions of interpersonal violence within the home, namely, intimate partner violence (Heyman and Slep 2002). Defined as a pattern of coercive tactics perpetrated by a current or former intimate partner, intimate partner violence is another global public health problem disproportionately affecting women, with an estimated one-third of women worldwide reporting partner violence (WHO 2014). Perpetration of physical child abuse is not, however, limited to those who commit partner violence. Both victims (Peled 2011) and perpetrators (McDonald et al. 2011) of intimate partner violence exhibit higher child abuse potential and more coercive forms of physical discipline. Intimate partner violence victimization of women during pregnancy predicts greater subsequent physical discipline use as well as child abuse by women and/or their partners (Chan et al. 2012), suggesting that intimate partner violence may precede child abuse. To account for such overlap, the spillover effect has been proposed as a possible process linking child abuse and intimate partner violence. According to the spillover hypothesis, the effect of disruptions or negative interactions occurring in one relationship or subsystem can transfer or “spill over” onto other relationships or

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subsystems in the family, resulting in additional disruptions or difficulties (Martin et al. 2017). As posited by family systems theory, individuals and subsystems in the family are interconnected; therefore, dysfunction in the parents’ couple relationship is likely to “spill over” to problems in the parent-child relationship. Couple dysfunction, as manifested in intimate partner violence, may prompt parents to use aversive parental discipline tactics such as harsh physical punishment that increase their risk of physical abuse. Thus, physical child abuse does not appear to occur in isolation, reflecting family dysfunction that can be expressed as physical abuse as well as other forms of family violence.

Risk and Protective Factors To assess a parent’s risk to physically abuse their child, a general risk measure of child abuse potential can be administered (cf. Milner 1994), although more specific risk factors are typically assessed to provide guidance on particular qualities to target within a parent in prevention and intervention programs. As in other forms of interpersonal violence, complex processes underlie why parents engage in physical abuse. Classical ecological theory has been applied to understanding child maltreatment (Belsky 1993) suggesting elements of the parents’ personal background, qualities within the family, and influences from the broader community interact and can cumulatively affect child abuse risk. Focusing on the aspects that affect the perpetrators of physical child abuse, who are the focus of this chapter (rather than qualities of their child victims), a number of significant intrapersonal historical and contemporaneous factors appear salient.

Intrapersonal Factors Lay perceptions of what leads parents to engage in physical abuse typically presume parents experienced a personal history of maltreatment – often termed the “cycle of violence” or the “intergenerational transmission of violence.” Parents with a history of physical abuse are five times more likely to report physically abusing their children than those without such a history (Kim 2009), with other research suggesting those with combined abuse and neglect in their childhood particularly likely to maltreat their own children (Bartlett et al. 2017). Despite the public’s firmly entrenched belief in a cycle of abuse, that cyclical process is far from certain. Some of the early estimates suggested 30% of parents who were abused perpetuate the cycle (Kaufman and Zigler 1987) – demonstrating that the remaining 70% do not. A careful analysis of the research on the intergenerational transmission of child abuse suggests estimates are highly inflated and are much more modest when limited to those with the most robust research designs (those with an abuse history perhaps twice as likely to perpetuate abuse; Ertem et al. 2000). Other childhood experiences, apart from physical abuse, have also been investigated as potential influences on parents’ later physical abuse of their children. For example, exposure to intimate

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partner violence during childhood increases the risk of those individuals later engaging in the physical abuse of their children (Black et al. 2001; Heyman and Slep 2002). Importantly, the evidence for considerable discontinuity in violence across generations underscores at least two groups that demand greater attention: those parents who initiate violence without a personal background of family violence in their childhood (suggesting different risk factors at work) and those parents who do not maintain the cycle of violence despite their own childhood history (suggesting protective factors at work). Prior research has indeed observed that the effects of the intergenerational transmission of child maltreatment weaken when simultaneously accounting for the adults’ current poverty and maladaptive functioning (Ben-David et al. 2015) – suggesting that the current context within which the adult is parenting remains critical notwithstanding their personal history. For example, personal problems – independent of their child – can serve to compromise parents’ overall functioning, distracting from their parenting. Indeed, mental health problems have been identified in parents who physically abuse, including general symptoms of psychopathology (Stith et al. 2009; Doidge et al. 2017), particularly depressive diagnoses (Black et al. 2001). Another mental health challenge identified among some physically abusive parents involves difficulties with substance use and abuse. Official statistics as well as national surveillance methods have suggested that substance abuse is particularly problematic for abusive parents of young children (DHHS 2018; Sedlak et al. 2010). Thus, mental health problems from either depression or substance use have been observed among parents who engage in physical abuse (Stith et al. 2009) and are issues often directly targeted in prevention programs (Klevens and Whitaker 2007). Even without formal mental health diagnoses, mothers and fathers who report more overall distress and stress evidence higher physical child abuse risk (Begle et al. 2010; Miragoli et al. 2018; Rodriguez and Tucker 2015; Schaeffer et al. 2005). The aforementioned spillover of intimate partner violence to child abuse may reflect how intimate partner violence represents a personal challenge for parents, contributing to stress and undermining mental health. These personal problems parents encounter, similar to many of the demographic characteristics, are likely to deplete their ability to devote the necessary attention and resources required to parent effectively, cultivating an environment wherein physical abuse can arise. Negative affect may be one of the by-products of these personal problems that exacerbate child abuse risk. Parents who feel overwhelmed with personal stress and mental health problems are more likely to experience negative affect, which could lead to greater aggression directed toward their children. Such negative affect appears to lower the threshold for parents’ inclination to use physical discipline, which thereby translates into an increased risk for physical abuse. This lower threshold may be manifest as lower frustration tolerance which is associated with parents’ physical abuse risk (McElroy and Rodriguez 2008; Rodriguez et al. 2015) because parents at risk to physically abuse may be more likely to experience annoyance (Montes et al. 2001) and to react impulsively (Black et al. 2001). Negative affect may be expressed as anger, which tends to amplify general

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inclinations toward aggression. Maternal anger increases physical discipline use (Ateah and Durrant 2005), and the negative affect characteristic of both stress and anger appears to increase physical abuse risk (Rodriguez and Richardson 2007). As a result, efforts to prevent physical child abuse often attempt to enhance parents’ anger management strategies (Klevens and Whitaker 2007; Poole et al. 2014). Negative affect – either sadness or anger – may simply serve to distract parents from their parenting responsibilities. Alternatively, parents’ negative affect may influence their cognitive processing. For example, negative affect may prompt parents to shortcut to more automatic, rather than conscious, processing during a physical discipline episode (see discussion, Milner 2000) – triggering them to react to their child with minimal cognitive processing. Negative affect may also initiate emotion-based, negatively biased “hot” processing of an event (rather than “cool” emotion-independent cognition), leading to the development of negative schemas (see discussion relevant to depression, where negative affect is prominent, Roiser and Sahakian 2013). In other words, negative affect may bias a parent’s cognitive processing during a discipline event (essentially converting “cold” cognition into “hot”; see Roiser and Sahakian 2013), potentially altering cognitions or initiating adverse cognitions. Therefore, negative affect may operate either as a distractor or as a factor that bypasses or biases cognitions. Overall, a clear picture of the affective underpinnings to physical child abuse remains relatively underdeveloped. In contrast to affective factors, considerable work has investigated the cognitive, conscious processing that place parents at risk to physically abuse. Such a cognitivebehavioral formulation has been proposed to reflect a social-information processing approach to predict parents’ physical child abuse risk (Milner 2000; Rodriguez et al. 2019). According to Social Information Processing (SIP) theory, parents’ cognitive schemas affect how they escalate their use of physical discipline that ultimately becomes abusive. In SIP theory, prior to engaging in any physical discipline, a parent already holds a range of beliefs about parenting and discipline – pre-existing schemas which may predispose them toward acting aggressively toward their child. Then, when a situation arises where a parent is faced with how to discipline their child, the parent undergoes a series of cognitions that can increase their likelihood of becoming abusive. First, the parent must accurately perceive what occurred in the discipline event (Stage 1); misperceptions can lead to erroneous conclusions on the part of the parent. The parent may then be inclined to evaluate the situation negatively (Stage 2) and fail to consider all pertinent information in deliberating how to respond to their child (Stage 3). If the parent elects to engage in physical discipline, in the last stage, they may not adequately monitor how intensely they are administering physical discipline (Stage 4), escalating toward physical abuse. One pre-existing schema involves parents’ approval of physical discipline. Parents who approve of physical discipline are more likely to use it (Ateah and Durrant 2005) and are more likely to evidence greater risk for child abuse (Rodriguez et al. 2011). In this regard, approval for the use of physical discipline with children is tantamount to a prerequisite for physical abuse – setting the stage for the potential escalation of physical discipline to become abusive. Another potential pre-existing

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schema that could increase abuse risk would be a parents’ inability to empathize with their child. Parents with greater empathic concern and perspective taking ability exhibit lower child abuse risk (McElroy and Rodriguez 2008; Rodriguez and Richardson 2007). Such an empathic response is consistent with whether parents develop an emotional connection and attachment to their child that would serve a protective role that would be associated with lower abuse risk (Counts et al. 2010). Cultivating such empathic abilities has thus been included in some prevention programs (Klevens and Whitaker 2007). Therefore, parents’ affective concern for their child, their ability to adopt another’s perspective, and their beliefs about discipline are both likely to be formed prior to any discipline event – examples of schemas that color a parent’s perspective before they ever encounter child behavior that prompts a response from them. Greater understanding of such pre-existing schemas represents an opportunity to identify cognitive processes at play prior to discipline events – ideal prevention targets. Physical child abuse risk is also higher for those who misperceive their child’s behavior, as proposed in SIP Stage 1. Parents with higher child abuse risk are inclined to view their children as problematic (Miragoli et al. 2018; McElroy and Rodriguez 2008; Stith et al. 2009). In this regard, research suggests abusive parents may experience problems with inaccurate attention, failing to accurately differentiate positive from negative child behavior or overlooking positive behavior while concentrating on negative behavior. Indeed, it appears possible that the negative affect evoked by depression leads parents to distort the extent of problem behaviors displayed by their children (see Gartstein et al. 2009). Parents’ negative affect may lower their tolerance of their children’s challenging behavior, leading them to perceive their child’s behavior more harshly and react more intensely to perceived aversive cues from their child. Such misperceptions may lead parents to evaluate their children’s behavior negatively, during SIP Stage 2. For example, parents who attribute more negative intent to their children’s behavior, ascribing malicious motives to their children, are more likely to evidence child abuse risk (Ateah and Durrant 2005; Montes et al. 2001; Rodriguez and Tucker 2015; Rodriguez et al. 2019). In other words, the parent’s evaluations of a child’s intentions in a given discipline episode appear to increase the parent’s abuse risk, potentially because such negative attributions are likely to enhance their justification for their discipline choice. During SIP Stage 3, parents who can integrate all information in the situation may be able to reduce their abuse risk – such as considering whether there are alternative explanations for their child’s behavior that may substitute for the hostile intent attributions ascribed to the child during Stage 2. For example, parents who consider mitigating explanations that alleviate perceived child responsibility can evidence reduced abuse risk (Irwin et al. 2014; Montes et al. 2001). Furthermore, parents with higher child abuse risk may also be unable to generate approaches other than physical discipline to address perceived child misbehavior, indicating that the inability to identify nonphysical discipline alternatives would increase physical abuse risk (Rodriguez et al. 2019). As a result, one of the frequent strategies adopted in child abuse prevention programs involves psychoeducation to parents regarding

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nonphysical discipline and positive parenting approaches (Klevens and Whitaker 2007; Poole et al. 2014). The final phase of SIP theory suggests parents may not be able to adequately monitor their own discipline administration, although very little research has directly assessed this element. One possible reason for such selfmonitoring difficulty may reflect poor inhibitory control, which is often apparent in anger and negative affect. Parents with diminished inhibitory control may be unable to notice the intensity of their implementation of physical discipline, which would facilitate the escalation to physical abuse. The “hot” processing from the negative affect a parent experiences could bypass earlier cognitive stages of SIP processing, leading parents to directly find themselves administering physical punishment in this phase, failing to supervise their own discipline use. However, this final phase of the SIP – admittedly a difficult phase to assess or witness directly – has seen the least research attention. Perhaps this omission in research inquiry of monitoring discipline implementation reflects its co-occurrence with affect, which is similarly unclear.

External Factors Apart from personal qualities of the parent, some aspects of the family ecological system level can also affect physical abuse risk. At this level, high family conflict has been reported in families with physically abusive parents (Schaeffer et al. 2005; Stith et al. 2009), suggesting that physical abuse risk may be associated with stronger family dysfunction (Tucker and Rodriguez 2014). And as previously noted, violence within the couple relationship can spill over to the parent-child relationship, increasing the likelihood of child abuse by either victims or perpetrators of intimate partner violence. Given evidence that better family functioning is considered a protective factor against child maltreatment (Counts et al. 2010), reducing family conflict is one of the components of some child abuse prevention programs (Klevens and Whitaker 2007). Outside the family, parents may seek support to address the personal mental health problems or parenting challenges they may be experiencing. But parents who are at risk to physically abuse are often characterized as socially isolated (Begle et al. 2010; Schaeffer et al. 2005). Indeed, increasing parents’ social support has been construed as a potential protective factor that could be cultivated to reduce parents’ physical child abuse risk (Counts et al. 2010; Rodriguez and Tucker 2015), included in many prevention programs (Poole et al. 2014). Factors in the immediate community may also play a role in physical child abuse risk. For example, parents’ abuse risk is higher in urban areas (MacMillan et al. 2013). Parents who perceive their neighborhoods to be dangerous demonstrate higher physical abuse risk (Begle et al. 2010). Social disorganization and adverse neighborhood conditions can increase parents’ stress to indirectly affect their abuse risk (a community-level aspect of prevention programs; Klevens and Whitaker 2007). The family dysfunction and neighborhood climate may contribute to parents’ stress that distracts from their parenting, whereas social support may offer parents

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relief, both in terms of instrumental and emotional support that alleviates that stress (Counts et al. 2010). At a wider community level, cultural norms can shape how parents view their role as a parent and as a disciplinarian including subcultural norms within groups in the USA (Malley-Morrison and Hines 2004). More broadly, cross-cultural research suggests higher prevalence and endorsement of violence at the societal level is related to individual parents’ more frequent use of physical discipline (Lansford and Dodge 2008). Nations that prohibit physical punishment experience lower rates of child maltreatment fatalities, and parents in those countries evidence lower approval for use of physical punishment with children (Gracia and Herrero 2008). National bans on physical punishment of children appear to affect parents’ attitudes and behaviors about its use (WHO 2014). Such cultural influences have implications for public policy that could reduce the risks of child abuse.

Protective Factors Similar to a number of areas in psychological research, compared to parental risk factors, the current literature on physical child abuse suffers from comparatively less inquiry into factors contributing to resilience or into protective factors that serve to reduce parents’ abuse risk. As noted above, enhancing parents’ social support systems and providing parents psychoeducation on discipline alternatives are considered options for reducing physical abuse risk. However, much of the literature in this area has evaluated the absence – or inverse – of risk factors as putatively beneficial. For example, lower self-esteem, poorer coping skills, and less partner satisfaction are considered risk factors for physical abuse (Black et al. 2001; Stith et al. 2009) – namely, that physically abusive parents express difficulties in those domains and thus those issues should be targeted in prevention programs (Klevens and Whitaker 2007). The implication is that higher self-esteem, stronger coping abilities, and improved partner satisfaction are then associated with lower abuse risk. But simply because an inverse relation may be extrapolated from the work on risk factors, whether such qualities serve an actual protective role is less frequently considered. In particular, research on whether one (positive) factor actually mitigates a risk factor to thereby lower parent’s child abuse risk (i.e., demonstrative of resilience) is limited. This sort of research requires an evaluation of moderation effects, in which a protective factor is not merely inversely related to abuse risk but also reduces the adverse effect of a separate factor. For example, although better family functioning was related to child abuse potential, it did not reduce the effects of parental stress (Tucker and Rodriguez 2014). However, stronger social support was observed to moderate the effects of personal history of child abuse and adults’ abuse risk (Litty et al. 1996) and to mitigate the effects of maternal distress and child abuse risk (Rodriguez and Tucker 2015; Tucker and Rodriguez 2014). Overall, not only has there been relatively little progress in identifying beneficial factors that promote lower child abuse risk, little work has identified factors that can also promote resilience despite adversity. Such beneficial factors may operate

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independently, rather than inversely, to risk factors – for example, a personal sense of faith, resilience, and optimism may not be simple inverses of risk.

Prevention Initiatives and Intervention Options Programs to prevent physical child abuse operate at three levels: primary, secondary, and tertiary prevention, representing universal, at-risk, or identified populations, respectively. Primary prevention occurs at the universal level to address modifiable antecedents of physical child abuse in the general population. These efforts typically concentrate on some of the risk factors noted earlier that have backing in the research literature (Klevens and Whitaker 2007). New population-level, public health strategies, such as media campaigns that can reach broad audiences and normalize participation in prevention programs, are also emerging (Poole et al. 2014). Although reviews of some primary prevention programs such as the Triple-P – Positive Parenting Program – appear promising, the vast majority of universal strategies have limited evidence available regarding their effectiveness (Poole et al. 2014). Secondary prevention programs are approximately twice as common as primary prevention strategies (Klevens and Whitaker 2007). This approach is more selective, targeting specific groups believed to be at risk for engaging in physical child abuse. These programs strive to address many of the risk factors noted earlier at the individual, family, or neighborhood level, such as lack of empathy, attributional biases, lack of knowledge of positive parenting techniques, family conflict, and social isolation (Klevens and Whitaker 2007). Although some specific programs appear to have negative or no effects on risk for physical child abuse, secondary prevention programs that screen for risk based on sociodemographic characteristics and/or parental psychosocial factors have a positive but relatively modest effect on reducing child abuse, with a mean effect size of 0.26 observed in one meta-analysis (Geeraert et al. 2004). Some of the most effective programs include the NurseFamily Partnership home visitation program and the Incredible Years Parenting Training Program for parents of children with conduct disorders (Poole et al. 2014). However, those programs with the highest effectiveness also demand the highest investment of resources and participant engagement – two persistent barriers for widespread implementation and utilization. Tertiary prevention represents intervention strategies to prevent recurrence of physical child abuse among parents who have already been identified as abusive and have been referred for treatment. Parent-focused programs tend to focus on increasing parents’ awareness of their alternatives to physical discipline, practicing child behavior management skills aligned with positive discipline principles, and providing treatment for mental health or substance abuse issues. A review observed a small number of evidence-based interventions with indicated perpetrators of child abuse (Oliver and Washington 2009). In those programs, often the parent-child dyad or the entire family is engaged in treatment. Parent training programs (such as Parent-Child Interaction Therapy [PCIT], Alternatives for Families: Cognitive

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Behavioral Therapy [AF-CBT], or Multisystemic Therapy [MST]) appear to modestly reduce repeat reports of physical child abuse (Vlahovicova et al. 2017); nevertheless, the evidence on treatments for parents who physically abuse remains limited. Considerably more rigorous research is needed to evaluate program efficacy and improve treatment outcomes. One continuing concern involves identifying issues that would improve retention during interventions, a major obstacle in the treatment of parents engaged in child abuse (Oliver and Washington 2009; Vlahovicova et al. 2017).

Future Directions One of the most critical delimiting factors in understanding parents who physically abuse their children involves the lack of a consistent operational definition of physical abuse across jurisdictions. The fact that a definition continues to elude us undermines the ability, for example, to identify who is engaged in physical abuse. Without clarity on who are the perpetrators, it is difficult to establish whether risk factors consistently apply across the spectrum of those engaged in any form of parent-child aggression. Moreover, identifying suitable comparison groups for studies evaluating prevention and intervention programs is complicated. This lack of clarity regarding the definition of physical child abuse is not mirrored in other forms of family violence, wherein any form of hitting a partner, for example, would be construed as physical intimate partner violence. Officially reported cases clearly represent a fraction of the physical abuse that is occurring. Thus, future work needs to evaluate the individual and systemic barriers experienced by mandated reporters to notifying authorities about suspected abuse as well as examine the limitations or weaknesses in current reporting guidelines. Mental health, healthcare, and educational professionals, for example, are mandated reporters in the USA – yet many do not report instances of physical abuse. Some studies have investigated factors that lead to these professionals’ reluctance to report abuse. For example, many avoid reporting potential cases either because they believe they must be certain of all details prior to reporting (rather than relying on protective services to conduct an investigation), because they believe they should not become involved in family affairs, or because they are concerned about damaging their professional relationship with those parents. Some have proposed a more nuanced reporting system wherein cases would be considered individually: those cases where a family has minimal support and monitoring might require more intensive oversight from child protective services, but families with ongoing relationships and routine monitoring (e.g., in mental health therapy) might prompt more protective services involvement only if that ongoing relationship terminates. Reporting suspected cases of physical abuse reflects a reactive approach that relies on the most observable signs of physical abuse that come to the attention of relevant professionals. Because child protective services are recognized to evaluate only the “tip of the iceberg” (Sedlak et al. 2010, p. 2–2), many child abuse cases are

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known to those working in schools, the justice system, and mental health agencies, among others. Many other cases are unknown to any agencies. Thus, a more proactive screening approach would pursue early identification of factors that may place parents at risk to engage in abuse by evaluating parents in venues they more routinely encounter. Primary care settings represent one such setting. Screening parents at well-care visits, for example, represents a potentially efficient way to quickly identify parents who might benefit from some assistance. Minimal research appears to have been conducted concerning the risk of physical child abusers to also engage in interpersonal violence outside of the family context, such as criminal, sexual, or gang-related violence that can occur in the community. Connection between physical child abuse and interpersonal violence outside of the home is therefore a potential interesting direction for future investigation. Given the indications that the prevalence and acceptance of societal violence relate to parents’ use of physical discipline (Lansford and Dodge 2008), parents who perpetrate physical abuse may be more inclined toward violence as a means of conflict resolution. On the other hand, parents who utilize aggressive conflict resolution approaches more broadly, outside the family, may represent a unique subset of parents identified as physically abusive with their children. Although a number of risk factors have been implicated in parents’ risk to physically abuse, further work is needed to clarify additional risk factors and, in particular, how they collectively relate to each other theoretically (e.g., Milner 2000). For example, research should consider to what extent multiple risk factors must be present in order to cross a critical threshold that would then suggest increased physical abuse (e.g., cumulative risk model; Begle et al. 2010). Alternatively, certain factors may be related to each other (e.g., Rodriguez et al. 2019), or different parents may be susceptible to different combinations of risks. Although a number of psychosocial determinants influencing physical abuse risk have been evaluated, remarkably little work has considered biological elements (cf. Gowin et al. 2013) that might also contribute to parents’ physical abuse risk in a more biopsychosocial model. Furthermore, noticeable in reviewing the limited scope of literature on resilience and protective factors, more research is needed to identify these important qualities, as they are key to informing more successful prevention and intervention efforts. One of the issues that limits current research on either risk or protective factors is a continuing reliance on self-report methods – a methodological limitation shared by many topics in psychology and not unique to the study of physical child abuse. But this methodological weakness is a particularly problematic one in this field given that parents may be motivated to misrepresent themselves. This weakness from self-report reliance has been acknowledged for decades, raising doubts about the conclusions of countless studies. Thus, innovative assessment approaches, such as measures that rely on implicit, indirect approaches to assessment (see Camilo et al. 2016), represent a promising direction to assess possible factors in a potentially more objective manner. Such indirect assessment approaches may use unconscious, implicit measurement of parents’ beliefs or

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approaches that involve behavior simulations designed to provide insights into factors that parents would be less able to manipulate. Using such indirect measures in a more multi-method, comprehensive manner (e.g., Rodriguez et al. 2019) provides an opportunity to determine whether a risk or protective factor indeed relates to child abuse risk. Continued progress is needed in retaining parents in treatment and improving the effectiveness of prevention and intervention programs. Empirical evidence for effective prevention strategies to address child abuse is generally mixed, limited, or weak (Reynolds et al. 2009). Often, it is unclear which elements of a prevention are critical toward program efficacy (Geeraert et al. 2004). Additionally, many prevention programs only evaluate factors hypothesized to decrease risk for child abuse, rather than actual acts of physical abuse (Klevens and Whitaker 2007). Although prevention programs that strengthen parenting skills and other family outcomes are beneficial, whether physically abusive behaviors are reduced remains unclear, particularly in the long term (Reynolds et al. 2009). More rigorous program evaluation studies are needed to ascertain the effectiveness of existing programs and identify the key components of treatment to target in future programs. Finally, a notable omission in much of the literature on physically abusive parents is the focus on assessment, prevention, and intervention with only mothers – despite the evidence of considerable physical abuse delivered by fathers and father figures (DHHS 2018; Sedlak et al. 2010) and that most injurious child abuse is from fathers (Starling et al. 2007). Some limited work has considered factors related to fathers’ child abuse risk (e.g., Heyman and Slep 2002; Schaeffer et al. 2005; Rodriguez et al. 2019), but the vast majority of research has concentrated on mothers. Indeed, most prevention and intervention programs have targeted mothers, essentially excluding fathers (Oliver and Washington 2009). Several barriers complicate fathers’ participation in both research and prevention and intervention programs, including their level of involvement in their children’s lives and in their families, which may fluctuate. Yet these barriers should be tackled to provide more opportunities for father engagement. Given that nearly half of physical abuse is perpetrated by male caregivers, considerably more research is needed targeting what factors are relevant for fathers’ abuse risk particularly because those factors may not be equivalent to those identified for mothers.

Public Policy Implications The role of the government – at local, state, and federal levels – is apparent in the surveillance and identification of physical child abuse. In the USA, the response to child abuse is prescribed by law in the Child Abuse and Prevention and Treatment Act, originally enacted in 1974 that provided for the development of child protective services, and was most recently reauthorized in 2010. This law provides a template for professionals, including research, assessment, investigation, criminal justice response, prevention, and treatment. In addition, many voluntary home visiting

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programs are coordinated with the Maternal, Infant, and Early Childhood Home Visiting Program, which is administered through the Health Resources and Services Administration in conjunction with the Administration for Children and Families, both within the US Department of Health and Human Services. The Adoption and Safe Families Act of 1997 required states in the USA to find permanent placements for children to avoid perpetual transient and fluctuating placements for children. Thus, the federal government can prescribe guidelines that are often implemented at more local levels. Some countries have mandatory reporting of child abuse, other countries have voluntary reporting guidance, whereas others have no official reporting of physical abuse; child protective services are available in only 69% of countries (WHO 2014). A continuing struggle for reporting and intervening with families has been managing the balance between children’s rights to safety and dignity (as described in the UN Convention on the Rights of the Child, article 19, para. 1) versus whether parents are entitled to raise children without outside interference. Federal policy changes have resulted in legal prohibitions of all forms of hitting children in over 50 nations – yet only a fraction of countries actively enforce such laws (WHO 2014). Whether societal attitudes approving of physical discipline precede or follow those bans is a subject of some debate, but as noted before, countries with such laws are more likely to have parents who disapprove of physical discipline (Gracia and Herrero 2008; WHO 2014). Thus, the potential for legislation to change both attitudes and behavior in parents is worth investigating. Policies for how identified cases of physical abuse are handled are often embedded in laws, although local jurisdictions often have differing interpretations stemming from ambiguity in the definition of physical child abuse. Local authorities also differ in their approach to placement decisions for children once physical abuse has been substantiated, including the conditions required for a child to remain in the care of a physically abusive parent rather than in temporary placements. Thus, federal policies may not always inform how local policies translate into actions within communities. The disparities between states and between nations on a variety of definitions and policies present an opportunity to empirically examine the policies’ relative effectiveness. Further, governments have an interest in promoting healthy families at minimum because of the fiscal costs of physical abuse, and that interest should translate into their investment in prevention efforts. The costs of physical child abuse largely arise from the response to and consequences of abuse after it has already occurred (Pereznieto et al. 2014). The bulk of the evidence examining global investments is that violence prevention is severely underfunded (WHO 2014). From a policy perspective, whether local, state, and federal resources are expended to address physical child abuse could be guided by consistent evidence that prevention dollars provide a multifold return on that investment (WHO 2014). As a consequence, policies about how federal, state, and local dollars should be spent warrant evaluation to determine how best to prevent parents engaging in physical child abuse in the first place.

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Key Points • Physical abuse is construed differently globally, affecting prevalence estimates. • Physical abuse is both pervasive and heavily underreported. • Parents who physically abuse are more likely to be involved in other forms of family violence. • Parents’ personal history of abuse does not account for most of those engaged in physically abusing their children. • Proximal affective and cognitive factors contribute to parents’ risk of physical abuse. • Clarifying risk factors and their interconnections continues to need attention. • Risk factors relevant to understanding child abuse for fathers remain limited. • To advance primary and secondary prevention efforts, improvements in screening for risk factors are needed. • Identifying protective factors and qualities that promote resilience is required to advance child abuse prevention efforts. • Countries disproportionately invest in responding to abuse relative to more costeffective prevention.

Summary and Conclusions Although some countries have implemented a legal definition of physical abuse to identify perpetrators of abuse, the scope of behavior that is included in such definitions varies widely across jurisdictions. Using inclusive definitions, the World Health Organization estimates that as many as 25% of children are physically abused worldwide. The vast majority of perpetrators are parents, and often those with the least resources (e.g., socioeconomic factors) are most likely to abuse their children. As a form of family violence, those who abuse their children are also more likely to be victims or perpetrators of intimate partner violence, indicative of family dysfunction. Considerable research has been conducted attempting to determine why parents engage in physical abuse. Although lay perceptions assume personal history of abuse is a primary mechanism in parents’ physical abuse of their children, more proximal factors appear to be most critical, including parents’ current mental health, affective and cognitive functioning, as well as external forces that can provide additional stress or influence their parenting beliefs. Much less attention has been paid to the factors that might reduce parents’ likelihood of physically abusing their children – namely, protective factors. Progress on prevention and intervention programs thus far has yielded modest success. Thus, renewed efforts are needed to better engage mothers and fathers in such programs targeting risk and protective mechanisms that may need to be tailored for the individual family’s strengths and weaknesses. Global investment in the prevention of physical abuse continues to be dwarfed by the costs spent responding to child abuse – a missed opportunity to avert the substantial personal and societal costs associated with physical child abuse.

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Cross-References ▶ A National Plan to End Interpersonal Violence Across the Lifespan ▶ Adverse Childhood Experiences: Past, Present, and Future ▶ Overview of Child Maltreatment ▶ Polyvictimization and Elder Abuse ▶ The Law and Policy of Child Maltreatment

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Contents Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Historical Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prior to Recorded History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Age of Antiquity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Medieval Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Age of Enlightenment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Modern Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Age of Children’s Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Legal Status of Corporal Punishment Today . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Corporal Punishment in Homes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Corporal Punishment in Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Corporal Punishment in Alternative Care and Child Care Settings . . . . . . . . . . . . . . . . . . . . . . . . Judicial Corporal Punishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Corporal Punishment in Response to Violations of Community Norms . . . . . . . . . . . . . . . . . . . Corporal Punishment and Political Conflict . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Current State of Research on Corporal Punishment’s Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . Outcomes of Corporal Punishment by Parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Outcomes of School Corporal Punishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Research on Children’s Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Prevalence of Corporal Punishment of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Challenges to Estimating Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Standardized International Prevalence Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Approaches to Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. J. E. Durrant (*) Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_13

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Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Corporal punishment of children reaches back at least to antiquity. Yet it is not universal. This chapter traces its history from pre-recorded history to the modern era, demonstrating the shifts in norms that have occurred over the centuries. The legal status of corporal punishment around the world is then examined, shedding light on the range of settings in which it occurs. The large body of research literature on corporal punishment’s outcomes is summarized, showing the degree of consistency in findings, as well as what has been learned from children themselves about the experience. Challenges to estimating the prevalence of corporal punishment are described, and standardized international estimates are presented. The chapter ends with a presentation of a range of approaches to its prevention. Keywords

Corporal punishment · Physical punishment · Punitive violence · Children · History · Attitudes · Prohibition · Prevention

Definition Corporal punishment is “any punishment in which physical force is used and intended to cause some degree of pain or discomfort, however light” (United Nations Committee on the Rights of the Child 2006). It is the most common form of violence against children worldwide (UNICEF 2017). Globally, 1.1 billion caregivers believe that corporal punishment is a necessary part of raising children, and it is estimated that 250 million children aged 2 to 4 years regularly experience physically violent punishment at home – two out of three children around the world (UNICEF 2017). Its most common forms are hitting – often called “smacking” or “spanking” – with a hand or object. But it can take a wide range of forms, including shaking, kicking, and biting; pulling hair or ears; burning or scalding; flogging or caning; and amputation. In some cases, the punishment is unlikely to leave physical signs but can cause intense discomfort – for example, forcing a child to ingest foul substances (e.g., hot spices, soap, and lemon juice); breathe smoke; stand under scalding or icy water; hold stress positions; dig holes or carry bricks under a hot sun; exercise to exhaustion; or kneel on hard objects (e.g., pencils, grits, uncooked corn). Other such punishments include withholding food or water or denying use of the toilet.

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Introduction For millennia, corporal punishment of children has been justified by religious texts, criminal laws, and cultural beliefs in the power of pain to engender learning. It remains one of few forms of violence that is still accepted, normalized, and prescribed, albeit to varying degrees across cultures. Tremendous effort has been invested over centuries by educators, parents, judges, physicians, policy-makers, and researchers to distinguish corporal punishment from physical abuse – the former being defined as a legitimate “strategy” or “technique” and the latter an act of “violence.” A scan of corporal punishment’s history reveals that these attempts to carve out a sphere of “non-abusive violence” have justified brutalities including beating, flogging, mutilation, and killing, as well as what we today call spanking, paddling, and whupping. Across history, we can find evidence of movements to end punitive violence against children – movements that have gradually lowered societies’ thresholds of tolerance. In colonial Massachusetts for example, children could be executed for disobeying their parents; by 2015, corporal punishment could not cause more than fleeting pain or transient marks. While this shift in threshold has been seen in many US states and beyond, the concept of “reasonable” corporal punishment remains strongly entrenched in most countries around the world. It is only in recent decades that we have witnessed a global movement to end all corporal punishment of children – a movement based on the findings of research and the recognition of children as bearers of human rights. By tracing the history of corporal punishment from pre-history to the present day, this chapter examines the cultural influences that have brought about change, as well as identifying those contexts in which punitive violence remains a serious problem. The urgent need to address the continuing legitimation of corporal punishment is then demonstrated in an overview of research showing its detrimental impacts on children’s physical and mental health. The challenges of tracking changes in attitudes and behavior within and between countries are summarized in a review of prevalence research. Finally, several approaches to shifting adults’ attitudes and strengthening their skills in nonviolent problem-solving are presented.

Historical Context Corporal punishment of children has a long history, dating back millennia. It is not, however, a universal practice.

Prior to Recorded History For most of human history, humans lived as hunter-gatherers. But practices and traditions in hunting and gathering societies can be highly diverse. Some have used corporal punishment, including beating and flogging. However, there is considerable

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evidence that corporal punishment of children is rarely found among those huntergatherer societies classified as egalitarian, which tend to share social norms that do not condone violence (Gray 2009). Anthropologists and missionaries (Diamond 2012; Gray 2009; Griffiths 2015; Hulbert and Schwartze 1910; Mowat 1952; Muir 2017) have documented the absence of corporal punishment of children in indigenous hunter-gatherer cultures of Australia (e.g., Yiwara), Brazil (e.g., Parakana), Congo (e.g., Aka, Efé), India (e.g., Nayaka), the Kalahari (Ju/’hoansi/!Kung), Malaysia (e.g., Batek), North America (e.g., Copper Inuit, Fox, Ihalmiut, Iroquois, Kiowa, Lakȟóta, Mojave, Tlingit), Philippines (e.g., Agta), Tanzania (e.g., Hadza), and the Trobriand Islands. As these cultures were colonized, rigid power structures were imposed, traditional parenting practices were prohibited, and corporal punishment was introduced. Its prevalence has been associated with increasing economic and political complexity, dependence on agriculture for food production, higher levels of socioeconomic inequality and power differentials, lower levels of democratic decision-making, and increasing reliance on nonrelative caretakers (Ember and Ember 2005, Gray 2009).

The Age of Antiquity Corporal punishment of children during the period of antiquity has been documented as far back as the Babylonian Code of Hammurabi (ca. 1754 BC), under which a son who hit his father would have his hands cut off. The earliest archaeological evidence of physical violence against a child comes from a 2,000-year-old skeleton discovered in Egypt of a toddler who had sustained a pattern of bone fractures indicative of repeated grabbing, shaking, and direct blows (Wheeler et al. 2013). The Old Testament Book of Proverbs (written tenth to sixth centuries BC) recommends beating children with a rod as correction: He that spareth the rod, hateth his son; but he that loveth him, chasteneth him betimes (13:24). Foolishness is bound in the heart of a child; but the rod of correction shall drive it from him (22:15). Withhold not correction from the child; for if thou beatest him with a rod, thou shalt deliver his soul from hell (23:13–14).

The Book of Deuteronomy (ca seventh century BC) recommends stoning a child for disobedience: If a man have a stubborn and rebellious son, which will not obey the voice of his father, or the voice of his mother, and that, when they have chastened him, will not hearken unto them (21:18): Then shall his father and his mother lay hold on him, and bring him out unto the elders of his city, and unto the gate of his place (21:19); And they shall say unto the elders of his city, ‘This our son is stubborn and rebellious, he will not obey our voice; he is a glutton, and a drunkard’ (21:20). And all the men of his city shall stone him with stones, that he die: so shalt thou put evil away from among you; and all Israel shall hear, and fear (21:21).

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Corporal punishment of children was common in parts of Greece (e.g., Sparta) and ubiquitous in Rome. Its impact, however, was questioned at least as early as the first century AD when the Roman educator, Quintilian, called corporal punishment of boys “a disgrace, and a punishment fit for slaves, and . . . an affront.”

The Medieval Period The Byzantine Empire (Eastern Roman Empire) brought corporal punishment into the Middle Ages. Throughout this era, the prevalence of public whippings, dismemberments, and mutilations ebbed and flowed. Regimented beatings, floggings, and whippings became increasingly common in schools, rationalized by beliefs that pain aids memory and fear is the root of wisdom and that such punishments can instill morality and obedience and condition both mind and body (Parsons 2015). Common tools of punishment were the lash, the cane, the birch (bundle of twigs), and the rod. According to the Glosae in Juvenalem (ca. 1130 AD), a medieval book of rhetoric, striking a child on the left hand with a rod would drive the blood to other parts of the body and stimulate the intellect (Parsons 2015). The French historian, Ariès (1962), describes discipline between the fourteenth and seventeenth centuries as a “humiliating system” (p. 250) that became widespread in societies that were authoritarian, hierarchical, and absolutist. In the early Middle Ages, corporal punishment was generally confined to the youngest children. After the sixteenth century, it was extended to all students, including those of university age, becoming “the ‘scholastic punishment’ par excellence” (Ariès 1962, p. 248). It was so common and so brutal that school became known as “a place of execution” (Ariès 1962, p. 249). Ariès considers the universal infliction of corporal punishment on all children, regardless of age or class, to mark the beginning of “childhood” as a separate stage of life: The whole of childhood, that of all classes of society, was subjected to the degrading discipline imposed on the [serfs]. The concept of the separate nature of childhood, of its difference from the world of adults, began with the elementary concept of its weakness, which brought it down to the level of the lowest social strata (p. 251).

The Age of Enlightenment Throughout the 1600s, Puritan values predominated in Britain. The Book of Proverbs was the guidepost; the primary aim of socialization was to break the child’s will. Fathers held total control over the family and were responsible for their moral and spiritual development. Corporal punishment, often through whipping and thrashing, was the route to salvation and was prescribed from infancy. During this period, corporal punishment in schools was particularly severe. Beatings and floggings were commonly inflicted for the smallest transgressions. Among the upper classes, however, the enlightenment brought about some moderation in ideas about corporal

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punishment. William Gouge (1622), a Puritan, advised that such punishment should be administered as a “last remedy” (p. 399), in love, without anger, accompanied by prayer, not extreme, and only for transgressions of God’s word which must be “purged out” (p. 401). The Scottish philosopher, John Locke, introduced new ideas about childhood, including the notion of “tabula rasa” which diverged sharply from the concept of original sin. He considered beating of children a form of tyranny and urged parents to replace it with reasoning and shaming – with the exception of obstinacy or rebellion, in which case “chastisement should be a little more sedate and a little more severe, and the whipping (mingled with admonitions between) so continued, till the impressions of it on the mind were found legible in the face, voice and submission of the child, . . . and [the child were] melting in true sorrow under it” (Locke 1693, p. 100– 101). Swiss philosopher Jean-Jacques Rousseau (1712–1778), on the other hand, argued for the rejection of all punishment “for [the child] does not know what it is to do wrong” (2013, p. 66). While questioning of corporal punishment of children was entering the public discourse in Europe, its practice was imported to North America by the Puritans, along with the concepts of original sin and the innate wickedness of children – ideas that were unthinkable among many indigenous cultures that viewed children as sacred gifts from the Creator – and savage punishments that included burning at the stake. Puritan justice led to Massachusetts (1646), Connecticut (1650), Rhode Island (1688), and New Hampshire (1679) passing “stubborn child” laws, under which boys over 15 years who disobeyed their parents could be executed, justified by the Book of Deuteronomy. Puritan discipline was also meted out to students at Harvard College, including whipping and other corporal punishments (Moore 1974).

The Modern Period In eighteenth-century France and England, some prominent thinkers argued against the brutality of “scholastic punishment” and questioned the idea that children deserved institutionalized humiliation. But progress along this pathway, which Ariès (1962) calls “the evolution of the collective conscience” (p. 251), was slow. During the Victorian era, when primary education became mandatory in Britain, the use of pain and degradation in schools did not abate. The cane and tawse (a strap with one end split into tails) were commonly used to beat children in front of their classmates. When physical punishments were eschewed, they were replaced by humiliations such as the “dunce’s cap” and the “punishment basket,” a wicker basket into which offending children were placed and raised to the ceiling by ropes and pulleys. Colleges like Eton sent thousands of students to the headmaster for “six of the best,” referring to six strokes of the cane. Corporal punishment was the norm in Victorian homes, as graphically described by Charles Dickens in David Copperfield and Great Expectations. With the growth of industrialization across Britain and its colonies, children were put to work in factories where they were beaten, whipped, and imprisoned as punishment. In the courts, children as young as 9 years were sentenced to lashes,

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birchings, and hard labor for stealing food. At the same time, Europe’s colonial powers were inflicting caning, amputation, flogging, stocks and pillories, and branding on adults and children in the societies they colonized and enslaved. Through the 1800s, Locke’s influence led to some reduction in severity of corporal punishments of children, which has been traced by Elizabeth Pleck (1987). She notes that whipping of children with branches and whips was gradually replaced by “spanking,” a word that entered common usage in the 1830s. The “official definition” of spanking included hitting with hands or with objects such as slippers or hairbrushes. But the word was often used in public discourse to describe being struck by buggy whips and switches. In 1839, the first parenting book to oppose all corporal punishment of children was published. The British surgeon, Pye Henry Chavasse, wrote: “My office is to inform you of everything that is detrimental to your children’s health and happiness; and corporal punishment is assuredly most injurious both to their health and happiness. It is the bounden duty of every man, and especially of every medical man, to lift up his voice against the abominable, disgusting, and degrading system of flogging” (Chavasse 2018, p. 215). It was during the nineteenth century that the idea of child protection emerged and the phrase “the rights of children” appeared. Children’s refuges and Societies for the Prevention of Cruelty to Children were created in England and the USA. But the staff often did not take action in cases of violence against children that did not leave marks, when the children said that they deserved to be whipped, or when the children had been disobedient (Pleck 1987). Thus, the child protection system, like the legal system, differentiated between “good” violence, which was deserved and corrective, and “bad” violence, which exceeded some arbitrary limits. This distinction between moderate and excessive force entered English common law in 1860, when a schoolmaster and follower of Locke beat an “obstinate” 15year-old student to death. The schoolmaster, Hopley, was charged and convicted of manslaughter. The judge ruled that “a parent or a schoolmaster. . .may for the purpose of correcting what is evil in the child inflict moderate and reasonable corporal punishment, always, however, with this condition, that it is moderate and reasonable” (R. v Hopley, [1860] 2 F. & F. 202). Punishment inflicted in anger, excessive in its nature or degree, beyond the child’s endurance, or with an object unfit for the purpose and with the intent to endanger the child was ruled unlawful. This ruling underpins many laws in existence around the world today. In 1889, the first child protection law was passed in England – The Prevention of Cruelty to, and Protection of, Children Act – which altered the legal relationship between parents and the state. The law was intended to permit intervention into the private sphere of the family before children were irreparably harmed, and it is applied universally regardless of social class. However, the act permitted corporal punishment. The London Society for the Prevention of Cruelty to Children, which led the efforts resulting in this law, made it clear that the intent was not to interfere “so long as the punishment is for real evil in a child and with a reasonable instrument, and for an endurable time” (Waugh 1892, p. 94, cited in Flegel 2009). Thus, as Monica Flegel (2009) has observed, a child’s own disobedience was

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considered a greater threat to the child’s well-being than an adult’s cruelty. Nevertheless, a formal framework for addressing violence against children was in place for the first time.

The Age of Children’s Rights In the early twentieth century, a movement to end child maltreatment began to emerge, championed by Ellen Key (Sweden), Janusz Korczak (Poland), and Eglantyne Jebb (England), all of whom viewed children as rights-bearers. Jebb wrote the first Children’s Charter, endorsed by the League of Nations in 1924 – but it did not address violence. Its descendant, the 1959 United Nations (UN) Declaration on the Rights of the Child, recognized the right to protection from cruelty, but this did not explicitly include corporal punishment. Throughout the century, concepts of human rights evolved, and a series of treaties were adopted by the UN. The most influential human rights instrument to address violence against children was the UN Convention on the Rights of the Child (CRC: UN General Assembly 1989). This treaty, which has been ratified by all UN member states except the USA, recognizes children’s rights to legal protection from “all forms of physical or mental violence” (Article 19). As has been the case throughout recorded history, many governments argued that corporal punishment is not violence. In response, the UN Committee on the Rights of the Child (2006) issued a general comment concluding that “‘all forms of physical or mental violence’ does not leave room for any level of legalized violence against children” (para. 18). As a result of the twentieth century’s recognition of children as persons and rights-holders, the world has undergone profound change in recent decades, with respect to corporal punishment. Increasing numbers of countries are prohibiting it in some or all settings. In the following section, the legal status of corporal punishment of children around the world will be reviewed.

The Legal Status of Corporal Punishment Today Corporal Punishment in Homes To date, 59 countries have fully prohibited corporal punishment in all settings, including the home. The primary purpose of these prohibitions is to affirm children’s full rights to protection in law. Their secondary purpose is to shift the entrenched social norms that perpetuate punitive violence against children. The first country to prohibit all corporal punishment of children was Sweden, in 1979: Children are entitled to care, security and a good upbringing. They may not be subjected to corporal punishment or any other humiliating treatment.

This law was placed in the Parents’ Code, a civil statute that does not carry criminal penalties. Its purpose was educative, not punitive. There is no evidence of an increased

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prosecution rate following its passage, and the number of children in out-of-home placements decreased substantially in subsequent years (Durrant 2019). With the near-universal ratification of the CRC by the early 1990s, 58 countries on all continents – except North America – have followed Sweden’s lead (www. endcorporalpunishment.org). These include countries in Africa (e.g., Congo, Togo, Tunisia), Asia and the Pacific (e.g., Mongolia, Nepal, New Zealand), Europe (e.g., France, Germany, Spain), Latin America (e.g., Argentina, Brazil, Uruguay), and the Middle East (Israel). Research on the outcomes of these laws indicates that they lead to substantial reductions in the social approval and prevalence of corporal punishment, without an increase in parental involvement in the criminal justice or child welfare systems (Durrant 2019). At this time, 54 countries have committed themselves to abolishing all corporal punishment of children in the near future. These countries are also highly diverse, including Bangladesh, Rwanda, and Thailand. But this list does not include the UK or the former British colonies of Australia, Canada, and the USA. These countries maintain laws that distinguish “punishment” from “abuse” and grant parents and others various degrees of protection from charges of assault. In New South Wales, Australia, the punishment must be applied below the neck and may not cause or risk harm that lasts longer than a short period. In Canada, parents may strike children between 2 and 12 years, below the head, with the hand, not in anger. In the USA, laws vary widely from Texas, which permits the use of non-deadly force, to Massachusetts, where force may not cause or create a substantial risk of physical harm.

Corporal Punishment in Schools School corporal punishment is prohibited in 132 countries (66%). Those countries where it is still permitted include Angola, Pakistan, Panama, and Saudi Arabia. The forms it takes vary from canings to holding bricks for a prolonged period to kneeling under the hot sun. In countries where it is prohibited, it may still occur if teachers are unaware of the ban, believe that corporal punishment is beneficial, lack knowledge of child development or positive discipline, or are required to focus on student conformity rather than questioning and independent thought. For example, in Afghanistan, where school corporal punishment was prohibited in 2005, it is used in 100% of classes in boys’ schools and 20% of classes in girls’ schools – most commonly in the form of beating with a stick (Samoon et al. 2011). The vast majority of Afghan teachers believe that corporal punishment is necessary and unavoidable; more than half were unaware that it was prohibited. In India, virtually all children are corporally punished at school; three-quarters of children have been beaten with a cane (Agrasar 2018; Portela and Pells 2015). Most of this punishment is for reasons related to poverty, such as school absences or dirty uniforms, or for typical child behavior, such as laughing. Children in India are also slapped in the face, beaten with sticks, or forced to stand for several hours with their hands raised. In some schools serving disadvantaged children, 88% are regularly beaten by their teachers (Agrasar 2018).

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Corporal punishment is permitted in public and private schools in 19 US states. Although the prevalence of school corporal punishment has declined from 4% of all students in 1978 to less than 0.5% in 2009/2010, some 160,000 children are still corporally punished every year, typically on the buttocks with a long wooden board (Gershoff and Font 2016). Most of these children are in elementary school. Corporal punishment is most prevalent in Alabama, Arkansas, and Mississippi. Boys and children with disabilities are at higher risk. Black children are much more likely to be corporally punished than White children – a disparity unchanged since 1976 – and they are punished more severely. This racial discrepancy has been traced to the lynchings of the post-Emancipation South (Ward et al. 2019).

Corporal Punishment in Alternative Care and Child Care Settings Alternative care settings include institutions and other forms of group care, formal foster care, hospitals, children’s homes, orphanages, and rehabilitation centers. Corporal punishment is prohibited in such settings in 65 countries (33%). Examples of punishments used in such settings include electric shocks (Cambodia, Turkey, the USA), beatings (India, Vietnam, Senegal), head shaving (Indonesia), canings (Uganda), food deprivation and isolation (USA), forcing children to stand in the hot sun (Mongolia), and tying up and hitting children (Turkey) (Global Initiative to End All Corporal Punishment of Children 2012). Forty US states and the District of Columbia have prohibited corporal punishment in all alternative care settings. Child care settings include nurseries, kindergartens, preschools, crèches, children’s centers, family centers, after-school childcare, childminding, and day centers. Corporal punishment is prohibited in these settings in 64 countries (32%). In the USA, it is fully banned in early childhood care and in child care for older children in 36 states.

Judicial Corporal Punishment Corporal punishment of children is prohibited as a sentence for a crime in 167 countries (84%). Countries where it is permitted include Afghanistan, Barbados, and Dominica. In countries where it is permitted, children can be sentenced to caning (e.g., Malaysia, Singapore, Tonga), flogging (e.g., Qatar, Nigeria), and stoning or amputation (e.g., Brunei, Iran). Between 2009 and 2019, 69 children were executed in Iran, Pakistan, Saudi Arabia, South Sudan, or Yemen (Amnesty International 2019).

Corporal Punishment in Response to Violations of Community Norms Corporal punishment may serve as an extrajudicial community-sanctioned response to violations of social norms. For example, acid attacks, burnings, and killings occur to punish violations of “family honor.” So-called honor-related violence is a planned

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response to perceived violations of family honor, most often perceived transgressions of sexual mores, initiated and carried out by the child’s family or husband. The victims are most often female. Historically, honor-related violence has been carried out in Latin America, the Middle East, North Africa, South Asia, and Southern Europe, but the number of cases in North America and Northern Europe is growing (Korteweg 2012). “Corrective rape” is employed to punish, correct, or “cure” children perceived as homosexual or otherwise non-gender-conforming. It is particularly prevalent in South Africa but has also been reported in Jamaica, Uganda, and Zimbabwe (Brown 2012). These acts, which can include gang rapes and stabbings, are often committed in the name of “teaching a lesson.” In some cases, a girl’s mother will invite a man to the home to rape the child. Forced marriage is, in some cases, a form of corrective rape (Gangoli et al. 2011). In virtually all cases of forced marriage, girls are threatened or met with corporal punishment if they do not obey their fathers or husbands.

Corporal Punishment and Political Conflict Children are more likely to experience corporal punishment in their homes during conflict and war, likely due to factors that immerse families in violence, erode parental mental health, and impoverish communities (Malcolm et al. 2017). Children in conflict settings also face an increased likelihood of corporal punishment outside of their homes. For example, they may become involved in protests against government authorities, a behavior punished with torture and/or killing in some countries. A 2011 report documented the beatings and deaths of four children aged 13 to 16 years at the hands of Syrian authorities in that year alone. Also in Syria, stonings and lashings of girls by ISIL have been documented (UN Human Rights Council 2018). In June 2019, Sudanese security forces killed at least 19 children attending an anti-government sit-in and injured 49. Two 17-year-old boys attending a protest rally in India were killed by police in December 2019. In many situations of conflict and war, sexual violence is used as a form of punishment. The UN has recognized rape as a weapon of war, used to humiliate and dominate. In Syria, for example, numerous rapes of girls and boys by high-level government officers and government-affiliated militias have been documented, in some cases as punishment for being associated with the opposition. Punitive sexual violence and forced marriage are also carried out by armed opposition groups (UN Human Rights Council 2018). During conflicts, armed groups may beat girls to punish them for attending school (Amnesty International 2011). In the process of recruiting child soldiers, armies, paramilitaries, and armed opposition groups may beat and/or abduct children who do not express a willingness to join them. During Sierra Leone’s civil war, thousands of girls – most between the ages of 9 and 19 years – were forced to marry their combatant-abductors and become soldiers and “bush wives.” Following that war, the Special Court for Sierra Leone became the first war crime tribunal to recognize

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forced marriage by armed groups as a crime against humanity (Park 2006). Once recruited, child soldiers are forced to commit atrocities under threat of severe punishment or execution (Human Rights Watch 2008). They are whipped, beaten, or killed for not obeying orders, retreating during combat, falling behind on marches, crying out when witnessing the execution of family members, or attempting to escape. They are often forced to inflict physical punishment on other child soldiers accused of desertion or other transgressions.

The Current State of Research on Corporal Punishment’s Outcomes Outcomes of Corporal Punishment by Parents By far the most research on corporal punishment’s impacts has been conducted in relation to parents and their children. Parents and other carers most often inflict corporal punishment to correct, control, or deter; in retaliation for a perceived affront to their authority; or as an impulsive reaction to stress, frustration, or anger. Its most powerful predictors are a belief that it is acceptable, experiencing it in childhood, and believing it was deserved in childhood. The body of literature on parental corporal punishment of children has surged over the past two decades, in parallel with the growth of research on children’s cognitive, emotional, social, and neurobiological development and growing recognition of children’s rights (Durrant and Ensom 2017). In the 1990s, research was largely focused on the links between “spanking” and child aggression, delinquency, and later spousal assault. These studies consistently found that corporal punishment was positively correlated with these outcomes. These findings raised the question of causal direction: Does corporal punishment produce aggression or does child aggression elicit corporal punishment? According to the methodological standards of the time, this question could only be answered with a randomized control trial (RCT). But the random assignment of children to a treatment condition requiring their parents to intentionally cause them pain is considered by most social scientists to be unethical. So researchers began to design prospective studies, equate children’s aggression levels at Time 1, or apply statistical modeling to shed more light on their findings. Several large prospective studies conducted in the early 2000s controlled for a range of potential confounders, including child sex, parent age, race, family structure, family socioeconomic status, and levels of emotional support and cognitive stimulation in the home. In these studies, corporal punishment at Time 1 consistently predicted antisocial behavior at Time 2. Research also began to uncover links between corporal punishment and mental health in childhood, adolescence, and adulthood – for example, depression, anxiety, hopelessness, unhappiness, psychiatric disorders, use of drugs and alcohol, and general psychological maladjustment. Other studies were finding associations between corporal punishment and poorer parent-child relationships. In a meta-analysis of 88 studies, Gershoff (2002) found that corporal punishment was consistently associated with solely negative

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developmental outcomes: child aggression (27/27 studies) and antisocial behavior (11/12 studies), poorer child mental health (12/12 studies), impaired parent-child relationships (13/13 studies), weaker internalization of moral values (13/15 studies), and heightened risk for physical harm (10/10 studies). Of the individual effect sizes analyzed, 94% represented negative outcomes. A later meta-analysis focused exclusively on studies of “spanking” – that is, striking children with the hand (Gershoff and Grogan-Kaylor 2016). This analysis of 75 studies found that even this normative form of corporal punishment is reliably associated with child aggression and antisocial behavior, externalizing and internalizing behavior problems, poorer parent-child relationships, lower moral internalization, and slower cognitive development. Of the 75 significant effect sizes analyzed, 99% represented negative outcomes. Moreover, these relationships were similar in magnitude to those found between severe physical abuse and the same outcomes. While it has been known for some time that physical abuse is a toxic stressor (Jaffee and Christian 2014), these findings suggest that even “spanking” should be classified as an adverse childhood experience. Indeed, in an analysis of the adverse childhood experience (ACE) database, Afifi et al. (2017) found that normative spanking increases the odds of suicide attempts, moderate to heavy drinking, and use of street drugs, meeting the criteria of an ACE. Recently, research has begun to examine the potential role of neurobiology in the relationships between corporal punishment and negative developmental outcomes (Gershoff 2016). More than 180 studies have found associations between childhood maltreatment and changes in the structure, function, or architecture of the brain (Teicher et al. 2016). Now studies are finding that physical punishment may reduce the volume of prefrontal gray matter and disrupt the dopaminergic regions linked with vulnerability to drug and alcohol misuse (Sheu et al. 2010; Tomoda et al. 2009). Such findings are erasing the putative line between “abuse” and “punishment” that has normalized punitive violence for centuries. Contributing to this shift is research consistently showing that most of what is called physical abuse is, in fact, physical punishment (Durrant and Ensom 2017). That is, the intent is not to harm but to correct. Furthermore, normative spanking greatly increases the odds of severe assault (Durrant and Ensom 2017). If parents’ expectations are unrealistic, children resist the force, or parents attribute the child’s behavior to willful defiance, the severity of the punishment can quickly escalate. In their meta-analysis, Gershoff and Grogan-Kaylor (2016) found that the spanking outcome with the largest effect size was physical abuse. The US Centers for Disease Control and Prevention has identified decreasing corporal punishment by parents as a promising strategy for reducing severe assault (Fortson et al. 2016).

Outcomes of School Corporal Punishment Findings on the outcomes of school corporal punishment are not as plentiful as those on parental punishment, but some correlational studies do exist (Gershoff et al. 2015; Straus et al. 2014). These show that students in schools or states that

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allow corporal punishment tend to have lower academic achievement and poorer executive functioning scores and higher levels of student violence, including more school shooting fatalities. Students who have experienced corporal punishment are more likely to have poorer peer relationships, more difficulty concentrating, lower academic achievement, and more somatic complaints and resentment of authority, and are more likely to avoid and drop out of school (Society for Adolescent Medicine 2003). One of the measurable impacts of school corporal punishment is the prevalence of injuries that students sustain. In the USA alone, 10,000 to 20,000 students require medical attention each year for injuries resulting from corporal punishment administered in schools (Society for Adolescent Medicine 2003). These include bruises, cuts, hematomas, broken bones, damage to muscles and tendons, eye injuries, and exacerbation of medical conditions of children with disabilities (Gershoff et al. 2015).

Research on Children’s Perspectives Only a few researchers have asked children how they feel about this experience. The first to do so were Willow and Hyder (1998), who interviewed 76 children aged 4 to 7 years in the UK. These children talked about “smacking” in terms of physical pain, emotional distress, feeling ashamed and embarrassed, and not liking their parents. In terms of smacking’s behavioral impacts, some children spoke about trying to do things right, apologizing, or learning from their mistakes, but a much larger proportion described crying, screaming, avoiding adults, being nasty, getting angry, and smacking back or smacking others. Willow and Hyder (1998) provided the text of the children’s responses, which illuminate the meaning of corporal punishment to children. For example, a 7-year-old said, “It feels as though you want to run away because they’re sort of like being mean to you and it hurts a lot.” Another 7-year-old said, “It kind of feels horrid, it just feels horrid, you know and it really hurts. It stings you and makes you feel horrible inside . . . ashamed inside.” Dobbs et al. (2006) used the same methodology to interview 80 children aged 5 to 14 years in New Zealand. These children described feeling fear, sadness, anger, unexpressed hatred, and a desire for revenge. In Australia, a sample of children described being smacked as intimidating, hurtful, and disrespectful, “like being treated like something very little and not important to the rest of the world” (Saunders and Goddard 2008). A US study documented anecdotal reports of students’ experiences with school corporal punishment in the USA (Human Rights Watch 2009). Outcomes included explosive anger, aggression, fear, terror, withdrawal, humiliation, broken trust, school avoidance, and severe emotional trauma. An understudied aspect of corporal punishment is its effects on those children who witness or hear it and the impact of spending every day under the constant threat of pain and violence.

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The Prevalence of Corporal Punishment of Children Challenges to Estimating Prevalence There are many challenges to obtaining accurate estimates of corporal punishment’s prevalence. First, young children tend to experience it the most, but they are the least likely people to be recruited into self-report studies. This leaves it up to adults to report on their own aggressive behavior, a method that is vulnerable to social desirability effects, lack of awareness of one’s actions, and inaccurate recall. In a study comparing mothers’ reports of corporal punishment to audio recordings of their actual behavior, their reports corresponded to the recordings in 81% of cases (Holden et al. 2014). This study also shed light on the frequency with which children experience corporal punishment; the median frequency was 18 times per week, which is considerably higher than rates found in adult self-report surveys. However, the enormous resources required to conduct such ecologically valid studies on a large scale render them virtually nonexistent. Thus, it is likely that available prevalence rates are underestimates. Second, if children are included as reporters, ethics become complex due to mandatory reporting laws in many jurisdictions. Researchers are required to decide whether to ask children to reveal the violence they experience, build in safety measures, and be prepared to report or to ask their carers to report on their own behavior, leaving many children’s experiences unknown and unreported and leaving those children unprotected. Third, the language used to define corporal punishment for the reporter can bias the findings. “Spanking” is considered a more acceptable act than swatting, hitting, slapping, or beating, even when no definition of it is provided (Brown et al. 2016). Thus, if a parent considers their action to be “spanking,” even if it included the use of an object or repeated blows, they will report it as such. Fourth, the research definition of corporal punishment is most often confined to hitting, with questions relating to whether an object was used and what part of the body was struck. Some measures include shaking, pushing, throwing, and punishment by example (e.g., biting a child as a punishment for biting). It is much rarer for measures to include acts such as forcing children to ingest food or other substances, hold stress positions, retain body wastes, hold weights, and submit to having their heads shaved and other physical punishments that are unlikely to cause injury. Fifth, researchers differ on their own definitions of acts constituting punishment versus those that constitute abuse. For some, hitting a child on the body is punishment, while hitting on the head is abuse. For others, hitting with the hand is punishment, while hitting with an object is abuse. Still others would consider hitting with an object punishment if it does not cause injury. These arbitrary distinctions not only lead to variability in prevalence estimates; they also affirm the idea that intentionally hurting a child as punishment is not necessarily a violent or abusive act, which contributes to the problem itself.

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Finally, it is difficult to obtain prevalence estimates in countries lacking infrastructure to conduct population-level studies. As a result, until recently, most prevalence estimates came from the USA and other highly developed nations.

Standardized International Prevalence Estimates From 1998 to 2003, the World Studies of Abuse in the Family Environment (WorldSAFE) used standardized methods and measures to obtain prevalence rates in six countries: Brazil, Chile, Egypt, India, Philippines, and the USA (Runyan et al. 2010). Mothers of children under 18 years (N ¼ 14,239) were interviewed using the Parent-Child Conflict Tactics Scale (Straus et al. 1998). They were asked how often they and/or their husband/partner had done each of the following: slapped the face, spanked the buttocks with a hand, hit the buttocks with an object, hit elsewhere with an object, hit the head with knuckles, pulled hair, pinched, twisted ears, forced a child to kneel or stand in one position, shook a child aged 2 years or older, and put hot pepper or spicy food in a child’s mouth (all classified as “moderate” physical punishment) and kicked, choked, smothered with hand or pillow, burned/scalded or branded, beat, and shook a child younger than 2 years (all classified as “harsh” physical punishment). The percentage of mothers reporting that the referent child had experienced any moderate or harsh physical punishment in the previous year are presented in Table 1. (For a breakdown of the prevalence of specific acts in each site, see Runyan et al. 2010.) UNICEF’s Multiple Indicator Cluster Survey (MICS), which began in 1995, has included a Child Discipline Module since its third round (2005/2006). It has been administered in more than 50 low- and middle-income countries (LMICs). Mothers/ primary caregivers of children aged 2 to 14 years are interviewed about punitive actions by any member of the household during the preceding month. An analysis was conducted of MICS data collected between 2005 and 2016 on 2- to 14-year-olds in 23 LMICs (UNICEF 2017). Among 2-to-4-year-olds, the percentage who had experienced corporal punishment in the previous month ranged from 28% to 80%. Among 5-to-14-year-olds, the range was 12% to 69%. Cuartas et al. (2019) analyzed MICS data collected between 2010 and 2016 from 49 countries on children aged 2 to 4 years (N ¼ 107,063). They estimate that 220.4 million of these children experienced corporal punishment, which corresponds to a Table 1 Percentage of mothers reporting that their child had experienced moderate or harsh physical punishment in the previous year, 1998–2003 Category of physical punishment Moderate Harsh

Brazil 70 2

Chile 69 5

Egypt 81 28

Indiaa 63–89 3–39

Philippines 83 10

USA 55 1

Separate rates were reported for seven sites in India. These figures present the range across those sites.

a

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prevalence of 62.5%. The highest prevalence was found in South Asia and subSaharan Africa. Lansford et al. (2010) interviewed 2,544 parents of children aged 7 to 10 years in nine countries about their use of punishment in the previous month. They asked parents to report whether anyone in the household had spanked, hit, or slapped with a bare hand; hit or slapped on the hand, arm, or leg; shook; or hit with an object. These acts were classified as “mild corporal punishment.” They also asked whether anyone in the household had hit or slapped on the face, head, or ears or beat the child repeatedly with an implement. These acts were classified as “severe” corporal punishment.” Their findings are presented in Table 2. Sweden, the first country to abolish all corporal punishment in 1979, stands out for its very low prevalence. Kenya is the only other country in this group to prohibit all corporal punishment, which it did in 2010, after this study was conducted.

Approaches to Prevention Many approaches have been developed to end corporal punishment of children. They range from individual-level interventions to universal public health messaging to law reform (Gershoff et al. 2017b). Targeted interventions reach parents who are identified as being at greatest risk, such as those already in the child welfare system. Examples of programs with demonstrated effectiveness in altering behavior or beliefs among this population are Parent-Child Interaction Therapy (Chaffin et al. 2004) and the Nurturing Parenting Programs (Bavolek and Hodnett 2012). Selective prevention programs are aimed at all parents, preparents, and professionals who advise parents. Examples are brief motivational interviewing methods (Holland and Holden 2016), home visiting programs (Howard and Brooks-Gunn 2009), and group programs such as Positive Discipline in Everyday Parenting (Durrant et al. 2017) and Adults and Children Table 2 Percentages of parents reporting mild and severe corporal punishment in the previous month China Colombia Italy Jordan Kenya Philippines Sweden Thailand USAa Full sample a

Mild corporal punishment 48 60 68 63 61 66 66 80 82 97 71 77 9 6 58 72 38 36 54 58

Parents in the USA were not asked about beating

Severe corporal punishment 10 15 15 4 12 23 21 31 61 62 9 8 0 0 5 3 4 5 13 14

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Together Against Violence (Knox et al. 2013). Other approaches use media, video, or computer platforms to disseminate information and provide supportive intervention (see Gershoff et al. 2017b). Many countries have introduced universal public education campaigns, such as Children See, Children Learn (see box). The Council of Europe launched a campaign in 2008 called, Raise Your Hand Against Smacking! which is accessible in 17 languages. A highly successful knowledge translation initiative in Canada – The Joint Statement on Physical Punishment of Children and Youth – disseminates information about corporal punishment and policy recommendations across the country. To date, it has been endorsed by more than 640 professional organizations representing all sectors, including health, education, child welfare, faith, First Nations, and immigration (https://www.cheo.on.ca/en/about-us/physical-punish ment.aspx). A similar initiative has been undertaken in the USA, the Report on Physical Punishment in the United States: What Research Tells Us About Its Effects on Children (http://www.phoenixchildrens.org/community/injury-prevention-cen ter/effective-discipline). A study conducted in five European countries (Bussman et al. 2011) found that public education alone is not as effective in changing attitudes and behavior as the combination of public education and legal prohibition. It is important that educational messaging is supported and affirmed – not undermined – by legal standards. The passage of corporal punishment prohibitions often launches government initiatives to prevent punitive violence; together these efforts can dramatically reduce corporal punishment’s prevalence (Durrant 2019). No Hit Zones

https://nohitzone.com This idea was created in 2005 by a professor of pediatrics to address the issue of corporal punishment of children in the hospital where she worked. No Hit Zones now exist in hospitals in many US states. An evaluation study found that a No Hit Zone decreased staff support for corporal punishment and increased their support for intervening when they witness it (Gershoff et al. 2017a).

Children See, Children Learn

https://childrenseechildrenlearn.ca Supported by Best Start Resource Centre and the Government of Ontario, this website provides videos of parents talking and interacting with their children, experts discussing discipline, and children behaving in typical ways at different developmental levels. It also provides tips for positive discipline and links to helpful resources. In its first year, it was viewed over 34 million times and shared 1.2 million times.

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Collaborative and Proactive Solutions (CPS)

https://www.livesinthebalance.org CPS is a nonpunitive and non-adversarial approach to resolving conflict with children. It addresses the underlying issues that are reflected in what is often called “challenging behavior.” By identifying the skills the child needs, teachers, parents, and others collaborate with the child to strengthen those skills. The model has been successfully applied in families, schools, group homes, residential facilities, and juvenile detention facilities.

Summary and Conclusion While corporal punishment is the most prevalent form of violence against children around the world today, it has not existed in all societies. It tends to be more common in countries with higher levels of inequality and lower levels of democratic decisionmaking. Thus, in the Western world, its prevalence has fluctuated through the centuries, depending on economic and social conditions. Today, knowledge about children’s cognitive, emotional, social, and neurobiological development is increasing at a rapid pace, virtually all countries of the world have ratified the UN CRC, and research findings on corporal punishment’s outcomes are remarkably consistent. Yet, prevalence rates remain high and laws do not provide adequate protection in most countries. Within this context, many approaches have been developed to support parents in learning other ways of responding to conflict with their children. These approaches show great promise in the effort to end punitive violence against children around the world.

Key Points 1. Corporal punishment of children is an ancient practice, but not a universal one. 2. While it has taken many forms, corporal punishment has consistently reflected a belief that children learn through pain and are deserving of violence. Most countries’ laws still justify the infliction of pain on children as “correction” in at least some settings. 3. To date, corporal punishment has been prohibited in schools in 132 countries, alternative care settings in 65 countries, child-care settings in 64 countries, and as a judicial sentence in 167 countries. It remains prevalent in some countries as a punishment for norm violations (e.g., “honor-related violence,” “corrective rape”), and as a means of control during political conflict and war. 4. Increasing recognition of children’s rights to protection and physical security has led to prohibition of all corporal punishment in 59 countries to date.

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5. Research on corporal punishment’s outcomes finds consistently negative impacts on children’s development, providing further support for its prohibition. 6. Challenges to tracking shifts in the prevalence of corporal punishment include reliance on adults’ self-reports, ethical issues in involving children as reporters, biases in measurement tools, and inadequate research infrastructure. 7. Where prevalence estimates have been obtained, they indicate that corporal punishment is a common childhood experience in many countries. 8. Approaches to preventing corporal punishment of children are growing, targeting all levels, from the individual to the cultural.

Cross-References ▶ A History of Interpersonal Violence: Raising Public Concern ▶ Adverse Childhood Experiences: Past, Present, and Future ▶ Child Physical Abuse: A Pathway to Comprehensive Prevention ▶ Corporal Punishment: Finding Effective Interventions ▶ Future Directions in Interpersonal Violence and Abuse Interventions Across the Lifespan ▶ Future Directions in Interpersonal Violence Prevention Across the Lifespan ▶ Implications of Maltreatment for Young Children ▶ Parents Who Physically Abuse: Current Status and Future Directions ▶ Trauma and Violence Across the Lifespan: Public Policy Advances, Challenges, and Future Directions

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Abusive Head Trauma: Understanding Head Injury Maltreatment

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Verena Wyvill Brown and Tamika J. Bryant

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Epidemiology and Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Timing of Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mechanism of Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Common Injuries or Findings in AHT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intracranial Hemorrhages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Parenchymal Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Axonal Injury and Hypoxic Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Neck and Spinal Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ocular Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Head and Facial Bruising . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Findings at Autopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Evaluation of Abusive Head Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . History-Taking and Multidisciplinary Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Imaging Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Laboratory Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Accidental Injury Versus AHT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mimics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Birth Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Benign Enlargement of the Subarachnoid Spaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rebleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Coagulopathies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Connective Tissue Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. V. W. Brown (*) · T. J. Bryant Children’s Healthcare of Atlanta, Atlanta, GA, USA e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_247

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Glutaric Aciduria Type 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Menkes Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Abusive head trauma (AHT) is a leading cause of death in physically abused children. It has been a recognized entity for many decades, although its nomenclature has evolved. This chapter begins by discussing the early history of AHT and its statistics, epidemiology, and risk factors. The above will be followed by the most important information in this chapter, which is the description of the clinical manifestations, biomechanics, and evaluation of children with suspected AHT, including how to obtain a medical history, important features of the physical exam, and diagnostic methods. We will also discuss mimics and their differentiation. Keywords

Abusive head trauma · Inflicted traumatic brain injury · Subdural Hemorrhages · Retinal Hemorrhages · Skull Fractures · Child Abuse · Child Maltreatment · Bruises · Spine · Shaken Baby Syndrome

Introduction Abusive Head Trauma (AHT) is the one of the leading causes of death from child abuse in children younger than age two, with an estimated 1,300 cases every year in the USA. Reviews of serious traumatic brain injury cases estimate that AHT is responsible for approximately 53% of deaths from physical abuse in children less than two years of age (Keenan et al. 2003). AHT occurs most often in children under 1 year of age, most commonly between 1 and 2 months (Parks et al. 2012). Findings in AHT were initially described by Caffey in 1946, when he looked at six cases of children with subdural hemorrhages and long bone fractures, some of whom also had retinal hemorrhages (Caffey 1946). AHT has been called by different names in the past, such as battered child syndrome (Kempe et al. 1962), whiplashshaken impact syndrome (Caffey 1974), and shaken baby syndrome, among others. In 2009, the American Academy of Pediatrics Committee of Child Abuse and Neglect made a recommendation to use the term Abusive Head Trauma. This terminology provides a better rubric to describe different mechanisms which can lead to traumatic injury from abuse, including shaking (Christian 2009). This policy, updated in 2020, continues to assert that abusive head trauma is well described in the literature and well accepted by pediatricians. The policy reaffirmed the dangers of

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shaking a baby and states that shaken baby syndrome is a valid diagnosis which falls under the category of AHT (Narang et al. 2020). Because child abuse is not only a medical diagnosis but also a criminal offense, cases of abusive head trauma are frequently discussed in a courtroom setting. The science is debated in the legal arena for the purpose of casting doubt in the minds of a jury. This has led to multiple alternative theories to try to explain the findings seen in AHT, including other injury mechanisms and disease processes. However, abusive head trauma is a welldescribed entity in pediatric medicine with consensus among pediatricians, neurosurgeons, ophthalmologists, radiologists, and other subspecialists around the world. In the scientific world, the existence of abusive head trauma and its findings are not debated (Choudhary et al. 2018; Lindberg et al. 2019; Narang 2011; Narang et al. 2016).

Definition The diagnosis of abusive head trauma, as described earlier, is the overarching term that encompasses any type of child physical abuse injury inflicted to the head, typically by a caregiver. This diagnosis can include bony injury to the skull, intracranial bleeding (i.e., subdural and/or subarachnoid hemorrhage), and injury to the brain tissue itself such as cerebral contusions and diffuse axonal injury. Spinal cord injury and eye injury such as retinal hemorrhages and retinoschisis may also be a part of the presentation. Abusive head trauma includes both indirect injury from trauma such as shaking, and direct trauma from impact related mechanisms. Secondary injury from ischemia, hypoxia, edema, and metabolic changes likely plays a part in the more severe outcomes from AHT (Christian 2009). There may be long-term effects and permanent disabilities which occur from AHT including developmental delays, blindness, seizure disorder, and cerebral palsy.

Epidemiology and Risk Factors Child physical abuse, and more specifically abusive head trauma, is not a problem that discriminates. Multiple studies have identified that infants younger than 1 year old and those who live in homes with lower socioeconomic status have higher rates of AHT (Nuño et al. 2015). However, these data should be interpreted with caution, as AHT occurs across all socioeconomic groups including children of different racial backgrounds and age groups. Families with various levels of education and differing levels of financial resources are affected by AHT. Boys have only slightly higher rates of physical abuse than girls. Because they are small and vulnerable, infants and toddlers have the greatest risk of severe and fatal abuse, including AHT (Christian 2015). Risk factors for the physical abuse of infants include various elements such as maternal smoking, having an unwed mother, and having low birth weight. Having more than two siblings also puts infants at risk (Christian 2015). Single motherhood itself may be a confounding factor, as it may be the increased likelihood of being left

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with unrelated caregivers that truly increases the chances of AHT occurring. There are multiple factors that may aid in the prevention of child abuse. Some of these factors include parental resilience, knowledge of child development, social connections, and the child’s ability to establish positive relationships. Therefore, childparent situations without these factors may be at increased risk for abuse. Parental resilience and knowledge of child development may be particularly important, as there appears to be an association of increased crying in infancy along with parental difficulty in managing crying which can lead to AHT. With increased incidence of abusive head trauma starting at 6–8 weeks of age, a time when infant crying normally increases, parents may seek to put an end to crying or react in frustration to crying (Christian 2009). This includes parents who do not have age-appropriate knowledge and expectations of child development, those with harsh parenting practices, and parents who lack empathy for their children. Children with disabilities are also at a higher risk for abuse than their counterparts without disabilities (Christian 2015). In 1995, Starling et al. looked at the relationship of perpetrators to their victims in cases of abusive head trauma. They defined perpetrators as caretakers who admitted to injuring the child, persons convicted in court, persons charged but not convicted, and those caregivers who gave a history that did not account for the injuries (Starling et al. 1995). They reviewed 207 medical records and identified 151 children that met criteria for the study. Ninety of the 151 children had both subdural hemorrhages and retinal hemorrhages (59.6%), 15 children had subdural hemorrhages and associated injuries (9.9%), and 46 children had subdural hemorrhages, retinal hemorrhages, and associated injuries (30.5%). Male caregivers (fathers, boyfriend of mother, and stepfathers) represented 60.6% of the perpetrators in the study with fathers being the largest group at 37% of cases. Male babysitters were perpetrators in 3.9% of cases. Female babysitters were identified as the largest group of female perpetrators at 17.3% of cases. Mothers were identified as perpetrators in 17% of the cases in the study (Starling et al. 1995). The conclusions of the paper were particularly relevant in considering the prevention efforts that were being undertaken in the area of child abuse. Given that prevention efforts at the time were often focused on young and expectant mothers, Starling et al. concluded that these efforts were not targeting the group most likely to cause this serious type of abuse (Starling et al. 1995). Adamsbaum et al. also examined perpetrators in 2010. In their case series, they also found that the majority of perpetrators were fathers and stepfathers (14 of 29) (Adamsbaum et al. 2010). A review by Nuño et al. in 2015 which examined the factors and outcomes associated with AHT found that in cases which had detailed information, father figures were identified as perpetrators in 64.8% of cases. Father figures included biological fathers as well as nonrelated male caretakers such as stepfathers and boyfriends. Mother figures accounted for 15.3% of all cases, followed by nonrelative caregivers (9.9%) and other family relatives (6.2%) (Nuño et al. 2015). Although these studies point to a preponderance of male caregivers as perpetrators, the data also shows us that female caregivers are also capable of perpetrating this type of abuse. Therefore, no particular type of caregiver should be excluded from consideration when evaluating abusive head trauma cases.

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In their review, Nuño et al. looked at 5195 children aged 0–23 months with abusive head trauma. They found the highest frequency of AHT cases in 2-monthold infants (16.1%), decreasing to 6.9% among 5-month olds and 1.4% in 13 month olds. Overall mortality rate in the 2015 review was found to be 10.8%. Looking at the breakdown of cases, the 0–11 month old cohort had a mortality rate of 9.8%, while the 12–23 month-old cohort had a mortality rate of 16.5%. Therefore, although children in the 0–2-month-old age group have higher frequency of AHT, it is the older infant that was at higher risk of death from AHT (Nuño et al. 2015). In 2020, Nuño looked at incidence and case fatality of AHT, with a focus on cases involving children between 2 and 4 years old. They looked at hospital discharge information from the Healthcare Cost and Utilization Project’s Kid Inpatient Database from the years 2000, 2003, 2006, 2009, and 2012, and used the Center for Disease Control definition for abusive head trauma. They found the average incidence per 100,000 children to be the highest in children less than 1 year old (27 per 100,000 children). This was followed by the next highest group at age 1 (4 per 100,000 children). The incidence continued to decline as children got older with rates of 3 per 100,000 children at age 2 and 1 per 100,000 children at age 3–4 years. In addition, males had a higher incidence of AHT than females in all age groups. They also found regional differences with an incidence of AHT that was consistently higher in the Midwest region for children in all age groups, except for a higher incidence for children age 2 years in the South (Nuño et al. 2020).

Clinical Presentation Severe head injury and death may be the presenting signs of AHT, but less severe injury occurs as well. Children may present to medical care with signs of neurologic derangement such as altered mental status, lethargy, irritability, seizures, or respiratory distress and apnea. They may also have poor appetite or vomiting. The most common symptoms initially reported by perpetrators are loss of muscle tone, vomiting, lethargy, and apnea (Starling et al. 2004). These initially present symptoms may also worsen over time, leading to more overt neurologic symptoms, including death. In a 2020 study by Babl et al., loss of consciousness, seizures, and a GCS less than twelve were more commonly demonstrated in children who presented to the emergency department with confirmed abusive head trauma (Babl et al. 2020). Less specific symptoms can include increased fussiness, altered sleep patterns, decreased appetite, frequent vomiting, or changes in activity. Other injuries may also be seen with medical evaluation, such as bruises, abdominal trauma, or broken bones. In situations of past or ongoing AHT, macrocephaly, developmental delays, or seizures, with or without other injuries, may also be seen (Hymel and Deye 2011). Common findings in abusive head trauma may include subdural hemorrhages, subarachnoid hemorrhages, retinal hemorrhages, hypoxic-ischemic injury, cortical vein thrombosis, axonal injury around the craniocervical junction, and other signs of

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abuse, such as fractures, bruises, and other injuries. These will be described in the subsequent sections (Hymel and Deye 2011). Two tools have been developed in order to predict the possibility of AHT in a patient. In 2013 and 2014, a four variable tool was derived and validated by the Pediatric Brain Injury Research Network (PediBIRN) to screen for AHT in children less than age three years in the pediatric intensive care unit. The four variables are as follows: (1) respiratory compromise before admission; (2) bruising to the ears, neck, or torso; (3) subdural hemorrhages and/or fluid collections that are bilateral or interhemispheric; and (4) skull fractures that are not isolated, unilateral, nondiastatic, and linear. Any child with one or more of these findings should be thoroughly evaluated for AHT (Hymel et al. 2014). Another tool that has been validated for children less than 6 months of age with intracranial injury is the Predicting Abusive Head Trauma (PredAHT) tool. Features listed in the tool that should elicit the concern for AHT include bruising to the head and neck, documented seizures, apnea either before hospital admission or during admission, rib fracture, long bone fracture, and retinal hemorrhages (Cowley et al. 2015). These tools can be helpful for medical professionals to determine whether or not there is a concern for AHT in individual patients.

Clinical Timing of Injury Altered mental status occurs immediately in cases of fatal head trauma (Arbogast et al. 2005). In nonfatal injuries, 65% will present with neurologic symptoms, whereas the rest will present with symptoms that are nonspecific, such as increased fussiness, vomiting, poor appetite, changes in activity, or changes in sleep (Hettler and Greenes 2003). Children with moderate to severe AHT will become symptomatic immediately after the injury occurs. Starling et al. described that in children whose caretakers had admitted to causing AHT, 91% had symptoms immediately after the assault (Starling et al. 2004). In less severe cases, significant symptoms may become apparent at a later time. Initially, children may have more nonspecific symptoms such as described above. It is important to note that children will not be completely asymptomatic after the injury occurs (Hymel and Deye 2011). Thus, when obtaining a medical history, it is important to determine as best as possible when the child was last acting normally and ask detailed information regarding the onset, duration, and progression of all changes in the child. This detailed information may help with the timing of injury. Using imaging to date injuries is imperfect and should be considered cautiously, as an acute subdural hemorrhage can have various appearances on a head CT. For example, subdural hemorrhages on an initial head CT may present as mixed density collections, with hypodense and hyperdense fluid. In the past, such collections would often be regarded as demonstrating two possible time periods of injury (one acute and one remote). Further investigation has shown that although this is one reason for the difference in densities, this is not always the case. In some instances, arachnoid tears may cause CSF leakage into a hyperdense subdural

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hemorrhage, making the hemorrhage appear mixed, isodense, or hypodense, leading to misinterpretation of the age of the collection. Other reasons which may lead to acute hemorrhages appearing mixed or homogenously isodense/hypodense in appearance include the presence of lower attenuation unclotted blood within a hemorrhage, such as is seen in some hyperacute hemorrhages, compacted clots in which serum separation occurs, or the presence of anemia. Thus, it is important for the modern clinician to shy away from using the “acute” and “chronic” terminology when describing subdural hematomas, and instead, describe the density observed (Wittschieber et al. 2019). Although brain MRIs may be more helpful with timing, clinical correlation is of utmost importance (Wright 2017), as a child may have subdural bleeds with varying intensities, but only have one episode of neurologic abnormality. In that case, only one injury episode can be diagnosed.

Mechanism of Injury Abusive head trauma can be caused by rotational injury to the brain via a contact mechanism, accelerating forces, or a combination of both (Hymel and Deye 2011). Contact mechanisms include high impact blunt force trauma, such as an infant being thrown onto the ground or into a wall, for example, creating coup-contrecoup injury. The coup injury is located underneath the area of impact, and the contrecoup injury is away from the area of contact, derived from inertial forces on the brain and surrounding tissues. Examples of such injuries include scalp contusions, skull fractures, epidural hematomas, focal subdural hematomas, and brain contusions. In mechanisms without impact, infants are commonly held by the chest, shoulders, or thorax and vigorously shaken such that the neck can no longer resist the motion, whipping the head to and fro. In these instances, the head is subjected to acceleration/deceleration forces (abrupt increase in velocity over time followed by an abrupt change in the direction of the acceleration), such that the brain rotates around inside the skull. The resulting strain (the measure of stretch or deformation of an objection subjected to a force) on brain tissue that occurs from angular acceleration (the velocity of rotation of an object) and inertially derived forces (a force directed in opposition to an accelerating force) is the main culprit in injury causation when strains applied exceed the varying tolerances of tissue strength. These forces cause stretching of bridging veins, leading to subdural hematomas. As anatomic regions with different material properties within the brain move at different centripetal accelerations, shearing of brain tissue due to differences in strain direction (longitudinal and transverse strain) occurs, leading to diffuse brain injury (Meaney et al. 2014). In addition to shear injury within the brain, deformation to the surface of the brain occurs as it strikes the inside of the skull, causing injury to the area of contact. Anatomic and physiologic properties of the infant brain render it more susceptible to rotational injuries in comparison to the adult brain. These include the large relative size of the infant head to the body, weaker neck muscles, as well as the fact that the infant brain has a higher shear modulus (modulus of rigidity), making it twice as stiff

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as the adult brain, and therefore less complaint to forces applied to it. This is because unmyelinated axons are more abundant in the infant brain; thus, the infant brain does not deform as much as the adult brain when subjected to strain. In addition, the relative compliance of the infant skull compared to the adult skull may decrease the amount of protection it can offer the infant brain (Coats and Margulies 2006; Hymel and Deye 2011; Marguiles and Coats 2011). Studies that have been done evaluating perpetrator confessions for mechanism and symptomatology describe shaking with or without impact as a cause for AHT. Starling and colleagues looked at 81 cases of confessed AHT. In 68% of cases, perpetrators admitted to shaking the infant, with 44% not describing an impact injury (Starling et al. 2004). Adamsbaum described 29 cases with a confession, and impact was uncommon. Statements from perpetrators included “I took her by the shoulders; I shook her and I yelled,” “I was holding my daughter under the arms, and I shook her. Her head wasn’t being held and was snapping back and forth,” “he was crying; it drove me crazy, I shook him . . . maybe 10 times, and threw him on the sofa,” “I shook her up and down, in front of me, without holding her against me; I was shaking her hard; I was crying just like she was, and I was worked up,” and several others (Adamsbaum et al. 2010). In addition to studies on perpetrator confessions, other models have been used to study AHT. There are no human subject studies available to study biomechanisms prospectively, as shaking an infant for scientific purposes, or any other reasons, would be unethical, extremely dangerous, and immoral. Thus, other biofidelic substitutes have been necessary and have yielded some success with demonstrating brain injury, extra-axial hemorrhage, and neurologic effects of shaking. Porcine models have been able to reproduce ocular hemorrhages from shaking (Coats et al. 2010). Wang and colleagues subjected mouse pups to repetitive shaking. The mice were found to have apnea and bradycardia, subdural hemorrhages and subarachnoid hemorrhages, parenchymal edema, severe lasting deficits in cerebral perfusion, and cognitive deficits, mimicking what is seen in AHT (Wang et al. 2018). Finnie et al. subjected lambs to shaking, resulting in axonal injury, retinal damage, and in some lambs, death (Finnie et al. 2012).

Common Injuries or Findings in AHT Intracranial Hemorrhages The rotation of the brain within the cranial cavity results in increased strain on superficial cortical veins, or bridging veins, causing them to break, leading to subdural hemorrhages. Subdural hemorrhages are one of the most characteristic signs of abusive head trauma (Ríos et al. 2009; Duhaime and Christian 2019). One Swiss study showed that they occur in 90% of cases (Fanconi and Lips 2010). In another study, evidence of bridging vein displacement or effacement was seen in the majority of cases of AHT. Direct trauma to the bridging veins was also seen in 44% of cases, which the authors described as the “lollipop sign” (Choudhary et al.

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2015). The “tadpole sign” is another name for this finding (Hahnemann et al. 2015). Subdural hemorrhages can occur via accidental injury, but the extent of injuries, including both what is seen radiographically and injuries of other areas of the body, combined with other symptoms may present a constellation of findings that would not be congruent with simple accidental injuries (Hymel and Deye 2011; Duhaime and Christian 2019; Christian 2015) (Figs. 1 and 2). Subarachnoid hemorrhages occur between the arachnoid and pial leptomeninges. They have been shown to occur in over 70% of AHT cases and are often focal, occurring next to subdural hemorrhages, skull fractures, or cortical contusions (Hymel and Deye 2011). In comparison to subdural and subarachnoid hemorrhages, epidural hemorrhages can happen more often in accidental injury, although they can also be the result of abuse. In most cases, epidural hemorrhages are accompanied by parietal skull fractures. Epidural hemorrhages occur when direct blunt force to the head causes rupture to a vessel and/or a tear to the dura (Hymel and Deye 2011) (Fig. 3).

Parenchymal Injury Cortical contusions, another injury that can be associated with AHT, can result from pure rotational injury to brain but more commonly occur with direct blunt force trauma to the head. They may be found in association with skull fractures or scalp hematomas (Gunda et al. 2019). Parenchymal tears (also referred to as contusional tears, parenchymal clefts, gliding contusions, or subcortical clefts) can be seen in young infants typically less than 5 months of age. They occur in white matter, while grey matter is spared, Fig. 1 Twenty-seven-day-old boy diagnosed with AHT. Depicted above is subdural hemorrhaging and parenchymal hemorrhaging

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Fig. 2 (a) and (b) The first image is an axial MRI, susceptibility weighted imaging sequence, depicting the tadpole sign. The second is a coronal CT also depicting the tadpole sign. (These images were submitted by Sarah Milla, MD, Children’s Healthcare of Atlanta, Radiology Department) Fig. 3 Six-month-old boy with a large epidural hematoma on the left, and an overlying parietal skull fracture. There were concerns for AHT versus an accidental fall. (This case was submitted by Children’s Healthcare of Atlanta trauma clinician, Susanne Hanada, RN)

due to shearing forces (Gunda et al. 2019). A 2016 study by Palifka and colleagues looked at the relative frequency of parenchymal lacerations in AHT versus accidental injury in two cohorts of children (one was comprised of children with confirmed cases of AHT, and the other cohort comprised children with accidental head injury).

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They also looked at the pattern of injury in 137 children younger than 3 years of age diagnosed with AHT. Although none of the children in the accidental injury cohort (18 children) had parenchymal lacerations, 13.1% of the 137 children with abusive head trauma had this type of injury. Lacerations were found more commonly in the frontal lobes, although they were found in various other brain regions as well. Most were found in the subcortical white matter. Other parenchymal injuries were present as well to varying degrees, including ischemic injury, shear injury, and contusion (Palifka et al. 2016).

Axonal Injury and Hypoxic Injury Hypoxic-ischemic injury is seen in approximately one third of children diagnosed with AHT and is found approximately four times more commonly in children with AHT than in those with accidental injury. Children with hypoxic-ischemic injury present with more severe signs and symptoms of AHT, including increased seizures and lower Glasgow Coma Scale scores. There are several theories regarding what causes hypoxic-ischemic injury in AHT, and the exact pathophysiology requires further exploration (Gunda et al. 2019; Orru et al. 2018). It is postulated that increased neuronal and glial strain elicits an excitotoxic cascade of complex biochemical reactions resulting in oxidative stress and free radical damage. Strain and injury to brain vasculature affects autoregulatory responses, leading to ischemia. These events eventually lead to further inflammatory responses, worsening and compounding existing injury, and perpetuating further injury (Hymel and Deye 2011; Meaney and Smith 2011; Rorke-Adams 2011; Christian 2015; and Orru et al. 2018). It is theorized that axonal injury can occur from a combination of angular acceleration/deceleration forces acting on the brain as well as from ischemic injury resulting from the traumatic insult. Because of the latter, axonal injury can worsen over time. Axonal injury is often found in the fiber tracts of the cerebrum, brainstem, and spinal cord and in the corpus collosum (Gunda et al. 2019; Hymel and Deye 2011; Rorke-Adams 2011). It has been postulated that it is hypoxic-ischemic injury from nontraumatic causes that leads to subdural hemorrhages. The argument is often made in the courtroom setting to say that trauma was not the culprit in the child’s injuries. However, studies of children who have had hypoxic-ischemic injury from medical causes demonstrate that children with hypoxic-ischemic injury do not have subdural hemorrhages as a result. For example, Kelly and colleagues looked at the incidence of subdural hemorrhages in newborn infants with congenital heart disease. One-hundred-fifty-two infants were followed from birth up to 3 months of age with serial brain MRIs. They were also stratified by levels of hypoxia. Fortythree percent of infants had subdural hemorrhages at initial imaging, and all were asymptomatic. Ninety-five percent of these hemorrhages had resolved by 2–3 months of age. The authors found no association with hypoxia and subdural hemorrhages, regardless of the level of hypoxia. The frequency of subdural hemorrhages seen neonatally in the infants in this study were congruent with the

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literature of subdural hemorrhages from birth trauma in the general population, and hypoxia did not increase their prevalence. Thus, they concluded that asymptomatic subdural hemorrhages in infants with congenital heart disease and hypoxia occur as frequently as they do in healthy babies with subdural hemorrhages due to birth trauma, showing that hypoxia does not increase the risk for subdural hemorrhages (Kelly et al. 2014).

Neck and Spinal Injury Spinal MRI imaging is important in the setting of AHT, as this imaging method visualizes the neck ligaments and muscles; CT imaging only permits visualization of the bony structures. CT scans of the spine are often negative, but recent studies have shown that cervical spinal ligamentous injury is commonly present in victims of AHT, with Choudhary and colleagues demonstrating a rate of 78% (Choudhary et al. 2012). One study also showed spinal canal subdural hemorrhages in 60% of AHT victims who underwent thoracolumbar MRI (Choudhary et al. 2014). Brennan looked at victims of AHT at autopsy, and 71% of those children were found to have cervical cord injury (Brennan et al. 2009). A recent retrospective cohort study from 2020 by Rabbitt et al. looked at 137 children under age five who underwent brain and spine MRIs due to concern for abuse. Sixty-one were found to have been abused, and seventy-six had accidental or indeterminate causes (injuries concerning for abuse, but other causes could not be ruled out). The MRI of the spine included the cervical spine through the upper thoracic spine, although some of the subjects also underwent an MRI of the whole spine. In the abusive head trauma group, 62% had abnormal results. In the accidental/indeterminate group, 55% had abnormal MRIs. The most common injuries were ligamentous injury, posterior paraspinous muscle edema, and prevertebral soft-tissue swelling. Compression fractures of the vertebrae were seen in some of the children. Cervical subdural or epidural hemorrhaging was noted, and whole-spine MRIs demonstrated lumbo-sacral spine subdural or epidural hemorrhaging in some of the children (Rabbitt et al. 2020) (Fig. 4).

Ocular Findings Eye findings often occur in conjunction with the intracranial injuries identified in AHT cases. When eye findings are present, they can be integral in establishing the diagnosis of child abuse. It is also possible to have cases of AHT with eye examinations that are completely normal, but the concern for abuse remains. Involving specialists both in the Child Abuse Pediatrics and Pediatric Ophthalmology fields is crucial in the overall evaluation when these patients present. It is important that the eyes be examined as quickly as possible in children with concern for AHT, preferably within the first 24 h. It is not known exactly how quickly eye findings may resolve, and there is no reliable way to time them via appearance. Therefore, waiting

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Fig. 4 MRI of the spine of a two-week-old boy diagnosed with abusive head trauma. Ventral epidural fluid from C3 to C7 and dorsal epidural fluid and edema extending from C6 to the thoracic spine is demonstrated

days to weeks for the dilated eye examination may result in missing key findings (Christian et al. 2018). When discussing eye findings related to child abuse, the injuries can involve a spectrum of presentations including direct external injury (such as subconjunctival hemorrhages and corneal abrasions) to indirect injury such as retinal hemorrhages and retinoschisis. Eye injuries can occur from direct blunt force trauma to the eyes or from the application of rotational acceleration force to the head, which causes the intracranial injuries described above. Given that indirect forces may cause injury, one cannot rely on visual indicators of eye pathology to determine who should have an examination by a trained ophthalmologist. According to the AAP, evaluation by an ophthalmologist should be completed when abuse is suspected in patients with visible eye injury, intracranial hemorrhage, coagulopathy, possible mimics of abuse, or unexplained altered mental status (Christian et al. 2018) (Fig. 5). Although other physicians may examine the eye, children who require an eye examination due to concerns for abuse should have their examination by an ophthalmologist using indirect ophthalmoscopy, along with dilatation of the pupil if at all possible. There may be issues that arise due to critical neurologic status that requires the monitoring of pupillary exam. In this situation, it is possible to use shorter acting medications for dilation and to work with the ophthalmology and managing teams to have one eye examined at a time. Externally, there are various injuries that can occur from trauma. Injuries such as periorbital swelling or bruising may be seen in both accidental and abusive trauma to the eye or forehead. Fractures to the orbit or frontal bone are not common in young children and are not frequently seen with abuse. Subconjunctival hemorrhages may be observed in young children related to abuse. They can be inflicted from direct trauma to the eye. They can also occur from other mechanisms such as situations that

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Fig. 5 (a) and (b) are from two different children with severe consequences from abusive head trauma. The child in the first image died from their injuries. The child in the second image was severely impacted. Both children had relatively mild retinal hemorrhages in comparison to their clinical picture. (Image submitted by Michelle Clayton, MD of Children’s Hospital of the King’s Daughters, Child Abuse Program)

cause increased intrathoracic pressure, birth, or medical disorders such as pertussis. Hyphema is the pooling of blood inside the anterior chamber of the eye. Traumatic hyphema can occur from blunt or penetrating trauma to the eye. This sort of traumatic injury can occur from either accidental or inflicted trauma (Christian et al. 2018). Retinal hemorrhages or hemorrhages that occur within the tissue layers of the retina can occur related to abuse, accidental trauma, and other medical conditions. However, retinal hemorrhages that are described as severe are strongly correlated with abusive head trauma, although they are not always present in cases of AHT. About 25% of patients with AHT do not have retinal hemorrhages. Of the AHT patients with retinal hemorrhages, their description may vary, including bilateral, unilateral, multilayered, confined to the posterior pole, or extending to the periphery. Retinal hemorrhages that are described as bilateral, in multiple layers of the retina, extending to the periphery, and too numerous to count are considered highly specific for abusive head trauma (Christian et al. 2018). It is also important to note that retinal hemorrhages that are not birth related cannot be accurately dated. A study has shown that intraretinal hemorrhages may resolve faster than preretinal hemorrhages and that retinal hemorrhages described as “too numerous to count” may resolve after only a few days (Binenbaum et al. 2016). In 2013, Maguire et al. performed a systematic review in order to address the question of the pattern of retinal hemorrhages and associated features that might help distinguish between AHT and nonabusive head trauma. They completed an all language literature search in order to identify articles published between 1950 and 2009. In order to minimize circularity, they excluded studies that relied solely on physical findings alone, those without a full multidisciplinary assessment, and those in which abuse was simply “suspected.” Abuse as an etiology was only accepted if there was admission, witnessed abuse, or at the least a full multidisciplinary assessment. The minimum accepted standard was that the study had to include

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examination by an ophthalmologist. The authors included 62 studies in their systematic review after removing abstracts and other studies that did not meet their criteria. Their overall data set involved 998 children, 504 of whom were diagnosed with AHT. This was a combination of 2 data sets. Data set 1 involved larger studies with consecutive cases. There were 363 children with abusive head trauma included in Data Set 1. Data set 2 involved highly selected case series, each with less than 10 subjects. Of the 363 children with abusive head trauma in Data Set 1, 283 (78%) had retinal hemorrhages. In contrast, among the group of 465 children with nonabusive head trauma, only 25 children (5%) had retinal hemorrhages. In regard to laterality in abusive head trauma, six studies recorded this information. They found that 81% (141/170) of children with abusive head trauma had bilateral retinal hemorrhages. Four studies recorded data regarding laterality in case of non-AHT. They found 8% (1/12) children with bilateral retinal hemorrhages in the nonabusive head trauma group. The single nonabusive head trauma case with bilateral retinal hemorrhages involved an 8-month-old infant who had ten retinal hemorrhages in each eye after a fall from a bed onto linoleum flooring. With regard to the number of retinal hemorrhages, 83% (60/72) of the cases of AHT had descriptions of larger numbers of retinal hemorrhages. None of the eight cases with the specific number of retinal hemorrhages described had extensive retinal hemorrhages (Maguire et al. 2013). They were unable to establish a prevalence for retinoschisis, as only one study described perimacular folds and none recorded the presence or absence of retinoschisis. In the case reports, there were three cases of retinoschisis described which involved crush injuries (2 from cofalls and 1 from a 19.5 kg television). While this shows that retinoschisis is not specific to abuse, it is consistent with retinoschisis being a traumatic finding. It is expected that a child with accidental crush injury from a fall with an adult or from a large object would present with a history of trauma related to their presentation. Therefore, retinoschisis in pediatric head trauma patients without an accompanying history of accidental trauma should still be considered highly suspicious for AHT. The authors concluded that their systematic review confirms that retinal hemorrhages have a strong association with abusive head trauma (Maguire et al. 2013). Of the retinal hemorrhages that were described in nonabusive head trauma, the descriptions were typically unilateral, few in number, and rarely with extension to the periphery. The authors call for the development of an international standard for the eye examination that included the site, location, and extent and level of retinal hemorrhages, in addition to the presence or absence of associated retinal features, such as retinoschisis (Maguire et al. 2013, p. 27) (Fig. 6). In 2016, Binenbaum et al. completed a retrospective chart review to look for patterns that might inform our knowledge regarding the natural progression of retinal hemorrhages associated with pediatric head trauma. They looked at patient charts from 2001 to 2009 and documented the eye findings at the initial examination and then continued examinations at intervals that extended to 4 months. Children were excluded if they had no retinal hemorrhages or if their first examination occurred beyond 72 h from time of presentation at the hospital (Binenbaum et al. 2016). In addition, information regarding subretinal hemorrhages were excluded due to inconsistent documentation. A number of important patterns were identified. Of the

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Fig. 6 (a) and (b) show retinoschisis identified on the eye examinations of children with severe abusive head trauma. These disruptions in the retinal layers are diagnostic of trauma. The child in the first image died from their injuries, and the child in the second image survived their injuries with serious residual sequelae. (Image submitted by Michelle Clayton, MD of Children’s Hospital of the King’s Daughters, Child Abuse Program)

91 eyes evaluated from 52 children, all of them had intraretinal hemorrhages at presentation. In 68% of eyes examined, the retinal hemorrhages were described as “too numerous to count.” Seventy-five percent of the eyes evaluated also had preretinal hemorrhages present at the initial examination. Given the knowledge that most children become symptomatic proximate to occurrence of their injuries, the assumption was made that retinal hemorrhages present at the initial examination had occurred recently. They found that too numerous to count retinal hemorrhages were only present on the initial examination. The pattern of children having only preretinal hemorrhages was first seen at the examination 1 week after presentation, and the number of eyes with only preretinal hemorrhages increased at subsequent examinations. The longest an isolated intraretinal hemorrhage was seen was 32 days. The longest an isolated preretinal hemorrhage was seen was 111 days. While the study had small numbers of study participants, it may provide important information regarding the way in which retinal hemorrhages progress. Intraretinal hemorrhages were consistently seen at presentation but resolved quickly, typically within 1–2 weeks. As time progressed, eye examinations increasingly had a pattern of only preretinal hemorrhages, which took much longer to resolve. Therefore, a pattern of numerous intraretinal hemorrhages at presentation suggests a more recent event, whereas the presence of only preretinal hemorrhages suggests that more time has passed since the abusive incident (Binenbaum et al. 2016) (Fig. 7).

Fractures Fractures of the face and skull are injuries that may occur from either abusive or accidental trauma. However, they are still important injuries to identify as they may

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Fig. 7 depicts the multilayer, too numerous to count (TNTC) retinal hemorrhage pattern that often seen in patients with severe abusive head trauma. (Image submitted by Michelle Clayton, MD of Children’s Hospital of the King’s Daughters, Child Abuse Program)

establish that impact has occurred related to the patient’s presentation. This can be especially helpful in the setting of a patient who presents with no history of trauma to explain what occurred prior to their arrival for medical treatment. Skull fractures, or their associated scalp swelling, may be the primary reason for the presentation of children with head trauma. These are common injuries in children, and accidental presentations are also common. Young children, especially those with limited mobility, should still be evaluated for abuse concerns when they present with facial and skull fractures. This should include imaging examinations, laboratory evaluations, and detailed histories obtained to ascertain the full extent of injury and possibilities for their cause. Skull fractures are often described as simple linear or complex. Complex skull fractures often involve multiple fracture lines and may be described as branching or stellate in nature. Simple linear skull fractures may occur from either abusive or accidental means. It is also possible for them to occur related to short falls. Potentially plausible presentations typically present with a caregiver offering a consistent description of the incident and subsequent caregiver actions. However, it is important that the full picture must always be considered. In addition, while thought to be more concerning, multiple or complex skull fractures must also have the full presentation evaluated, as these may also represent accidental injuries. Studies have shown that both complex and simple skull fractures may be consistent with either abusive or accidental injuries (Hughes et al. 2015). Epidural hemorrhages are often seen in association with skull fractures. Since they are both due to blunt force trauma, there is a high likelihood they will occur together. When impact occurs to a particular area of the skull, often the parietal bone,

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there is in-bending that occurs causing rupture of a cerebral artery, often the middle meningeal artery. When skull fracture is not present, it is likely that although an impact occurred that caused in-bending of the skull, the skull bone did not bend to the point of failure (fracture). While abuse cannot be completely ruled out in this setting, fractures with associated epidural hemorrhages are frequently seen from accidental mechanism. However, an abuse assessment should evaluate the circumstances of injury, the age and developmental ability of the child, and the presence of additional injuries (Figs. 8 and 9). Facial fractures, such as orbital roof or frontal bone fractures, may also occur from accidental or inflicted means. Maxillary or mandibular fractures can also be

Fig. 8 (a) and (b) Twenty-seven-day old boy diagnosed with AHT. Depicted above is the 3D reconstruction from a head CT showing a left parietal skull fracture

Fig. 9 8-week-old infant with scalp swelling found to have calcifying cephalohematoma

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abusive or accidental. Frontal or orbital roof fractures are often seen related to falls with significant impact to the face. While not specific for abuse, the presence of this injury in a child without a presenting history of accidental trauma should still raise the concern for abuse. Mandibular or maxillary fractures may occur from direct impact or from indirect trauma to the face, such as impact to the chin. Evaluation with CT, particularly maxillofacial CT, is most helpful in fully evaluating these injuries.

Head and Facial Bruising Bruising to the head and face can be important findings in children who are victims of abuse. For small infants, especially those with limited mobility, facial bruising may be the initial indicator that abuse is occurring. These so-called “sentinel injuries” are the small or subtle injuries that may occur in young children which should prompt further evaluation for abusive trauma. Sentinel injuries are often found on review of previous presentations for care in children who present with significant or fatal physical abuse. Other examples of sentinel injuries include intraoral injuries (e.g., abrasions or torn frenula), or other injuries such as fracture (Sheets et al. 2013). Bruising of the head has been shown to be particular important in identifying patterns concerning for abuse. TEN-4 is a clinical decision tool that was developed from a case-control study that evaluated bruising in children that were admitted to the Pediatric Intensive Care Unit (PICU) due to trauma. The study involved 42 patients who were victims of abuse and 53 control subjects who were admitted for accidental trauma during the same study period. The tool was created by documenting the bruises and their characteristics for all patients, including the total number of bruises and the region where the bruising was located. The study established that in children less than 4 years old, bruising of the trunk, ears, and neck (TEN) is particularly concerning for physical abuse and rarely occurs from accidents. In addition, it established that any bruising in children less than 4 months old is concerning. The rule, named “TEN-4,” helps recall the need to apply it in children less than or equal to 4 years old and also helps clinicians remember that all bruising in children less than 4 months old is concerning. It is important to remember that “Kids that don’t cruise, don’t bruise” (Pierce et al. 2010).

Findings at Autopsy Thorough postmortem evaluations of fatalities due to abusive head trauma may uncover pathologic findings that further contribute to the constellation of injuries. Reflection of the dura will show subdural hemorrhages, typically on the cerebral convexities and in the cranial fossae. Subarachnoid hemorrhages will often be seen along the cerebral parasagittal convexities. With removal of the eyes with the optic nerve and attached surrounding fat, optic nerve hemorrhages are often seen, with

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Fig. 10 Autopsy photograph of subdural hemorrhages overlying the cerebral convexities in a nine-monthold victim of AHT

hemorrhage in the surrounding fat as well. The eyes and optic nerve are fixated and sliced to evaluate for retinal hemorrhages, retinoschisis, and vitreous hemorrhages. The brain itself is also fixated and sliced. Traumatic diffuse axonal injury can be seen in these slices. Contusion tears appear as slits in the cortex-white matter junction and in the lamina of the cortex. Immunohistochemical staining can show microscopic damage to axons (Case 2014) (Figs. 10 and 11). In addition to the pathology seen in the brain itself, autopsies may uncover other pathology such as rib fractures, metaphyseal and other long bone fractures, cutaneous and subcutaneous bruises, and injuries to other organs, such as liver lacerations, lung contusions, bowel injuries, and any number of other injuries concerning for or indicative of physical abuse.

Evaluation of Abusive Head Trauma History-Taking and Multidisciplinary Evaluation During the evaluation for AHT, obtaining a detailed medical history is key. This history should include past medical history and family medical history such that an understanding of underlying medical problems in the child and family is established. The social history can often be an undervalued aspect of the medical history. This area of the history should help identify household members, recent and regular

Fig. 11 (a) and (b) Autopsy photographs depicting optic globes and attached optic nerves with optic nerve sheath hemorrhages in a nine-month-old victim of AHT

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caregivers of the child, and stressors in the family such as unemployment, financial concerns, recent moves, job changes, and the like. The social history should also screen for other concerns that may increase the concern for abuse or neglect such as the presence of parental or caregiver mental health diagnoses, caregiver substance abuse issues, previous child protection and law enforcement involvement, and the presence of interpersonal violence in the home. It is clear that children who are in a home where child abuse or neglect has previously occurred are at increased risk for continued maltreatment. However, in addition to this, the exposure to interpersonal violence in the home places children at increased risk of physical abuse (Holden 2003). Also, the exposure to interpersonal violence is in itself a type of maltreatment as these children are at a minimum experiencing emotional and psychological abuse. Although it varies by state, many states have laws that define exposure to domestic violence as child maltreatment, which is therefore reportable to the states’ child protection agency (National Clearinghouse on Child Abuse and Neglect Information 2004). The medical history should also include a detailed timeline of the recent course of events and condition of the child. It is helpful to begin with when the child was last known to be well, with a clear description of their condition and appearance at that time. It can be beneficial to obtain a description of normal activities that they are observed to have been doing at that time such as eating, smiling, playing, and walking. Once the baseline condition is established, obtain a timeline of what occurred with the patient moving forward until their presentation at the hospital. With a concern for AHT, it can be helpful to understand when there was onset of symptoms such as irritability, fussiness, vomiting, lethargy, and loss of consciousness. In addition to the condition of the child, it is necessary to gather information regarding the child’s caregivers and all the people who were present during the time that the child’s symptoms became apparent and evolved. This information can be crucial in helping child protective services and law enforcement in their approach to the investigation. Of course, any information provided regarding traumatic events that have occurred are particularly important and should include details such as type of trauma, types of forces (i.e., blunt force trauma), objects involved, and types of surfaces involved (i.e., wood flooring vs. carpet). The history should also include information regarding any alleviating actions that were taken once symptoms were noted such as medication given or cardiopulmonary resuscitation administered (Christian 2009). With a complete and through history and appropriate laboratory, imaging, and eye evaluation, the concern for abuse can be properly evaluated. It is with input from all the multidisciplinary professionals involved that the concern for abuse can be adequately addressed. Establishing the proper diagnosis is imperative and requires that thorough and thoughtful evaluations be performed.

Imaging Evaluation The evaluation of abusive head trauma continues to evolve with the improvement of imaging modalities such as MRI. Timely head imaging remains the mainstay in

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evaluating children for abuse, especially when there is a concern for head trauma. The American College of Radiology (ACR), Appropriateness Criteria for Suspected Physical Abuse in Children, and the American Academy of Pediatrics Policy Statement on Diagnostic Imaging of Child Abuse both provide reasonable guidelines for the evaluation of physical abuse in children (AAP 2009; ACR 2016). As it relates to AHT, the AAP guidelines state that children with a suspicion for intracranial injury must undergo cranial computed tomography (CT), magnetic resonance imaging (MRI), or both. CT without intravenous contrast is a great imaging modality for screening, as it is widely available at medical facilities and can be performed quickly (AAP 2009). The necessary images can often be obtained in a few seconds and therefore can usually be obtained without the need for sedation. CT is also considered to be generally better in identifying acute (new) hemorrhage. It also tends to be very helpful in identifying skull fractures and overlying soft tissue swelling. CT head, therefore, remains the initial recommendation for evaluation in these patients (AAP 2009). The ACR Appropriateness Criteria for Suspected Physical Abuse in Children provides examples of clinic presentations in children with suspected physical abuse. It rates imaging modalities in categories of 1–3 (usually not appropriate), 4–6 (may be appropriate), and 7–9 (usually appropriate), regarding their appropriateness for use in various types of pediatric patients with suspected physical abuse. The criteria are organized by different “variants,” which are broad clinical categories used to describe how a patient might present. Variants 1 and 2 deal with children who present without signs or symptoms suspicious for neurologic or visceral injuries. Variant 3 provides the example of a child with “one or more of the following: neurologic signs or symptoms, apnea, complex skull fracture, other fractures, or injuries highly suspicious for child abuse” and makes recommendations for the initial imaging evaluation. The modalities identified as “usually appropriate” include the CT head without IV contrast (usually performed in the emergent setting), and brain MRI without IV contrast (usually performed in the nonemergent setting). Also identified as “usually appropriate” is the MRI cervical spine without IV contrast. MRI complete spine without IV contrast and Tc-99m whole body bone scan are identified as “may be appropriate” with the clarification that the bone scan is typically used as a problem-solving study and not a first-line study (ACR 2016). The Appropriateness criteria text identifies unenhanced CT as the examination of choice to evaluate children with suspected abusive head trauma. CT also allows for 3-D volume rendering that can increase the sensitivity for fracture and intracranial hemorrhage (ACR 2016). MRI provides increased sensitivity in detecting small extra-axial hemorrhages and parenchymal injury. It may also be able to identify other injuries such as diffuse axonal injury. It should be noted that thrombosed bridging veins identified on MRI should also raise the level of suspicion for AHT (ACR 2016). Spinal injury can be seen in children with AHT. Spinal subdural hemorrhage and ligamentous injury at the cranial cervical junction can also be identified in these cases. Spinal subdural hemorrhage is seen in 36–78% of cases, and ligamentous injury is seen in 4463% of cases (ACR 2016). The clinical value of

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screening the entire spine is, as of yet, unclear. While imaging of the full spine may detect otherwise unidentified injury, it is not clear that thoracolumbar subdural collections represent direct trauma to that area of the spine; instead, blood collections in that region may represent a redistribution of blood products. Identifying the presence of thoracolumbar subdural hemorrhage may help differentiate between abusive and accidental injury. In one study, a cohort of 38 children with AHT had thoracolumbar spine imaging, and their study findings were compared to 70 accidental trauma patients who had thoracolumbar spine imaging. Among children with AHT, 24 (63%) had thoracolumbar subdural hemorrhage, compared to 1 patient with thoracolumbar subdural hemorrhage in the accidental trauma group (Choudhary et al. 2012). Ultrasound has limited utility in the evaluation of children with AHT. It is not as sensitive in identifying many of the concerning intracranial injuries that we are attempting to identify with this evaluation. However, ultrasound can play an important part in making a distinction between infants with subdural and subarachnoid collections. This could assist in differentiating macrocephalic infants with traumatic subdural lesions from those infants with benign enlargement of the subarachnoid space in infancy (BESSI), a nontraumatic condition. Since ultrasound is not sensitive in identifying small subdural hematomas and other traumatic brain injuries, it is important that infants have evaluation with one of the other modalities if trauma is a concern (AAP 2009).

Laboratory Evaluation In addition to the radiologic evaluation for children with abusive head trauma, it is important to obtain various laboratory studies (Christian 2015). These studies will aid in screening for injuries affecting other systems, such as with elevated liver enzymes seen in abusive abdominal trauma. These laboratory studies also aid in screening for diseases that may mimic AHT such as bleeding disorders. The recommended laboratory evaluation in cases of suspected physical abuse can vary based on the presentation. However, in cases with abusive head trauma concerns, a complete blood count (CBC), PT/INR, PTT, Factor VIII level, Factor IX level, fibrinogen, and d-dimer are recommended. In general, patients will also have lab tests obtained that will evaluate for other trauma which should include liver enzyme tests (aspartate aminotransferase (AST) and alanine aminotransferase (ALT), pancreatic enzymes (lipase), and urinalysis. These laboratory studies can be particularly helpful in identifying abdominal trauma, and often help in determining the need to do abdominal imaging. If cutaneous bleeding or bruising is a concern, von Willebrand activity (ristocetin cofactor) and antigen should be added to the bleeding evaluation. Additional studies that should be considered with head trauma are review of the newborn screen in infants, urine organic acids to screen for glutaric aciduria type 1, and a Factor XIII level. When in doubt regarding the workup for easy bleeding or bruising, consultation with a pediatric hematologist can be very helpful (Christian 2009).

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Although the laboratory and imaging evaluations of children are very important, the multidisciplinary evaluation of these children and their families is equally important. Involvement of a trained specialist in the evaluation of children with concerns for abuse or neglect is key. In addition to this specialist, there often is involvement of a general or intensive care unit pediatrician, team or hospital social worker, child protective services investigator, law enforcement investigator, and other subspecialists such as neurosurgeons, ophthalmologists, and geneticists. Involvement of child protective services and law enforcement often leads to a community response to the concern for child abuse that may involve various courts, attorneys, judges, and juries, all with the goal of ensuring safety and justice for the potential victims of abuse.

Accidental Injury Versus AHT One of the main questions that medical professionals need to answer when evaluating children for possible abusive head trauma is whether there is an accidental mechanism that can explain the constellation of findings seen. A common mechanism provided to explain injuries is that of the short fall. Falls from small heights of 4 ft or less, such as from couches and beds, can certainly cause minor injuries, such as linear parietal skull fractures or a minor bruise (Reece and Sege 2000). However, the literature is clear that most short falls do not cause the constellation of symptoms seen in abusive head trauma. In 2008, Chadwick et al. performed a literature review of published materials over a 5-year period in the National Library of Medicine regarding fall injury data in young children. The authors found that of 2.5 million children included in the data, only six cases of death were possibly fall-related for falls less than 1.5 m (4.9 ft) in height. Thus, they calculated that risk of mortality for short falls in young children is less than 0.48 deaths per million (Chadwick et al. 2008). Another mechanism commonly presented as an explanation for inflicted injuries is a stairway fall. Although stairway falls initially appear more likely to cause serious injury, such falls have been generally shown to cause minor injuries as well. In a study by Chiavello et al., 69 children with a history of stairway falls whose mean age was 2 years were evaluated prospectively. Head and neck injuries were found in 90% of the patients, but most of the injuries were minor as defined by their Modified Injury Severity Scale. Twenty-two percent suffered more significant injuries, including 16% with concussion, 7% with skull fracture, 3% with cerebral contusion, 1 child with a subdural hemorrhage, and 1 child with a C-2 fracture. No deaths occurred, and most patients had one single injury, with 3 out of 69 having more than one significant injury. One of these patients with more than one injury fell while being carried by a caregiver (Chiaviello et al. 1994). A case series by Atkinson et al. described cases of subdural hemorrhages due to occipital impact. The series described eight witnessed short falls in young children, mean age 12.5 months, who fell backward, hitting their heads against a hard surface. All children had symptoms immediately. The falls were of varying heights, such as from a highchair, a bed, and standing height. Two of the children were pushed

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backward by other children. Six out of the eight children had unilateral subdural hemorrhages. All had retinal hemorrhages of various degrees. None of the children described in the study had retinoschisis. One of the children who was pushed by another child onto cobblestone (child fell on top of patient) died 19 days after the injury. This injury was witnessed by multiple family members, thus validating the medical history. The child’s findings included subdural hemorrhaging overlying the frontal, parietal, and temporal lobes and cerebral edema, similar to what we see in cases of abusive head trauma. Nevertheless, most of the children improved within 24 h. Thus, obtaining a thorough medical history with a detailed mechanism and then corroborating the history is extremely important in evaluating accidental versus nonaccidental head trauma (Atkinson et al. 2018).

Mimics There are several different disease processes that may present with findings that are also seen in abusive head trauma. Birth injury, benign enlargement of the subarachnoid spaces, coagulopathies (such as Factor 13 deficiency), metabolic diseases (such as Menkes Disease and Glutaric Aciduria Type 1), and some genetic diseases sometimes can present with findings that are overlapping. However, laboratory testing, radiologic findings, histories, and physical exams can differentiate these entities from AHT.

Birth Injury Subdural hemorrhages can occur from birth trauma. These injuries are most commonly not clinically significant. Significant symptoms occur in the immediate postnatal period, most commonly demonstrated by poor feeding, apnea, bradycardia, and seizures (Choudhary et al. 2018). A study by Rook and colleagues investigated the incidence and natural history of subdural hemorrhages due to birth injury. Out of 101 infants, 46 of them had subdural hemorrhages. These occurred from both vaginal deliveries and Cesarean sections, and all of them were asymptomatic. A prolonged labor seemed to add to the risk for subdural hemorrhages. Most hemorrhages were resolved by 1 month of age, and all were resolved by 3 months of age. Thus, subdural hemorrhages seen after the third month is likely not the result of birth trauma (Rooks et al. 2008). Similar findings were seen in a study by Kelly and colleagues, who looked at the prevalence of subdural hemorrhages in infants with congenital heart disease. In their study, 43% of 152 infants had subdural hemorrhages in the neonatal period. All were asymptomatic, and most were resolved by 2–3 months of life (Kelly et al. 2014). Risk factors for subdural hemorrhages due to birth trauma include instrumentation during delivery and abnormal labor (Towner et al. 1999). Retinal hemorrhages can also be seen due to birth injury. Much like subdural hemorrhages, they are usually not clinically significant. One third of infants have

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retinal hemorrhages, and they can be numerous and extend to the periphery. In 85% of cases, retinal hemorrhages resolve within 2 weeks after birth. Therefore, at one month of age, too numerous to count retinal hemorrhages extending to the periphery are not due to birth trauma (Binenbaum et al. 2016).

Benign Enlargement of the Subarachnoid Spaces Benign enlargement of the subarachnoid spaces (BESS) is the most common cause of macrocephaly in infants. The subarachnoid space enlarges, leading to an increase in head circumference, commonly between 3 and 12 months of age (mean 7 months). Often infants will have one close male relative with macrocephaly. Most commonly, no other signs or symptoms are seen, although gross motor delay can be found on occasion. Stabilization of head circumference is typically seen by 18 months (Khosroshahi and Nikkhah 2018). BESS is associated with a small increased risk of subdural hemorrhages. Nevertheless, children who present with subdural collections should receive a thorough evaluation to rule out abusive causes (Greiner et al. 2013; McKeag et al. 2013) (Fig. 12).

Rebleeding When a child has a chronic subdural hemorrhage, rebleeding can occur. This is a common phenomenon that is typically clinically insignificant. Rebleeds are usually found incidentally on follow-up imaging after the original injury. When a child has a rebleed, they do not have the symptoms associated with an acute injury. In 2019, Wright and colleagues studied 143 children with subdural hemorrhages due to abusive head trauma. Eighty-five percent were reimaged by either CT or MRI

Fig. 12 Seven-month-old female infant who presented with an enlarging head circumference found to have benign enlargement of the subarachnoid spaces of infancy (BESSI)

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after their initial injury. Sixty-four percent of the children who were reimaged were found to have rebleeding. Ninety-two percent of them were asymptomatic. Two percent had abnormal head growth, and 3.5% had seizures, but the seizures had begun at the time of original injury. The study noted that no new acute neurologic symptoms were associated with the rebleeding (Wright et al. 2019). Thus, it should not be assumed that subdural hemorrhages in newly symptomatic children are due to rebleeds, even if they have both acute and chronic appearing components.

Coagulopathies When children present with intracranial hemorrhages, retinal hemorrhages, and bruises, it is important to consider and rule out bleeding disorders that may predispose the child to bleeding. Hemophilia and other factor deficiencies, such as Factor 13 deficiency, von Willebrand disease, leukemia, thrombocytopenia, aplastic anemia, platelet function deficiencies, fibrinogen disorders, and Vitamin K deficiency, among others, could present initially as mimics to AHT. However, there are diagnostic clues that can differentiate a bleeding disorder from AHT, including the clinical presentation and history, family history, and laboratory workup. In 2013, Carpenter and colleagues wrote a technical report for the American Academy of Pediatrics summarizing bleeding disorders that could be potentially confused with child abuse (Carpenter et al. 2013). Hemophilia A and B (factors VIII and IX deficiency respectively), are X-linked recessive disorders that in severe cases can present with bleeding into joints, bleeding into soft tissues, and intracranial hemorrhage. Intracranial hemorrhages in the face of hemophilia can occur from birth trauma, minor trauma, or spontaneously. The estimated rate of occurrence of intracranial hemorrhage is 5–12%. Laboratory results demonstrate a low factor VIII or IX, and in moderate to severe cases the activated partial thromboplastin time may be prolonged. The technical report also summarizes deficiencies in factors II, V, VII, X, XI, and XIII. It is important to note that although factor XIII is an extremely rare autosomal recessive disorder, occurring in 1 in 2–5 million people, a common initial presentation is intracranial hemorrhage (Carpenter et al. 2013). Von Willebrand disease may present with increased risk of mucocutaneous bleeding. However, in most cases, the presentation is mild. The likelihood of intracranial hemorrhage in von Willebrand disease is extremely rare. Laboratories to test for the disease include von Willebrand antigen (vWAg), von Willebrand activity (ristocetin cofactor), and factor VIII activity. A von Willebrand multimer analysis is also often used (Carpenter et al. 2013). Vitamin K deficiency may also present with alterations in coagulation, as it is needed for the proper functioning of factors II, VII, IX, X, and proteins C and S. Infants who do not receive Vitamin K at birth are at an increased risk for bleeding early in the neonatal period, including intracranial hemorrhages. The literature also shows delayed cases of intracranial hemorrhages with Vitamin K deficiency. Schulte and colleagues described seven cases of infants with confirmed Vitamin K deficiency

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due to not receiving Vitamin K at birth. All of them had profound changes in coagulation, and four had intracranial hemorrhages. The mean age of presentation was 10.3 weeks. All improved with Vitamin K administration (Schulte et al. 2014). Biliary atresia, bile salt transfer defects, and other disorders that affect Vitamin K utilization may also present with disruptions in coagulation (Christian and States 2017).

Connective Tissue Disorders Some connective tissue disorders can on rare occasion be confused with abusive injuries. Ehler-Danlos Syndrome (EDS) is a group of genetic connective tissue disorders which has six subtypes. Each subtype has a different presentation, clinical history, inheritance pattern, and biochemical defect. The most common subtypes are in the mutations of collagen I, III, and V. Easy bruising, bleeding gums, skin hyperextensibility, and joint hypermobility are often seen. Type IV EDS is the vascular type of the disease and can more easily be confused with abusive injury because of its features. All forms of EDS can cause a greater propensity for bruising and bleeding due to abnormal capillary structures. Type IV can present with excessive bruising, spontaneous bowel rupture or hemorrhagic pneumothorax, or vascular ruptures. However, intracranial hemorrhages are uncommon and do not present with the same symptoms as those seen in abusive head trauma. In type IV, other characteristics include prominent eyes, small lips, lobeless ears, hollow cheeks, and a pinched nose. Skin hyperextensibility is not typically seen with EDS type IV. Nevertheless, the skin does not appear normal. Rather, it has a translucent appearance (Carpenter et al. 2013) (Fig. 13).

Glutaric Aciduria Type 1 Glutaric Aciduria type one is a rare, autosomal recessive metabolic disease characterized by a deficiency in the glutaryl-CoA-dehydrogenase enzyme. This enzyme in the mitochondria helps to convert tryptophan, lysine, and hydrolysine to Fig. 13 Wormian bones in a child with osteogenesis imperfecta. (Image submitted by Stephen Messner, MD, Children’s Healthcare of Atlanta, Child Protection Team)

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Fig. 14 CT scan depicting widened Sylvian fissures in a child with Glutaric Aciduria type 1 and macrocephaly. (This image was submitted by Sarah Milla, MD, Children’s Healthcare of Atlanta, Radiology Department)

acetocacetyl-CoA. Without this enzyme, glutaric acid and 3-hydroxyglutaric acid accumulate, causing toxicity (Vester et al. 2015). Children often present with macrocephaly and an encephalopathic crisis within the first 3 years of life. Abnormalities seen on imaging include the batwing sign, or widening of the Sylvian fissures, in 93% of patients. Cortical atrophy and enlargement of the ventricular spaces with expansion of cerebral spinal fluid can also occur. Theoretically, this may cause bridging veins to stretch, thus leading to the increased risk of subdural hemorrhages (Vester et al. 2016) (Fig. 14).

Menkes Disease Menkes Disease is an x-linked recessive disorder affecting copper metabolism. It is typically diagnosed early in the first year of life. Signs and symptoms include delays in growth, developmental delay with loss of milestones, seizures, and connective tissue abnormalities. Dull, curly, wool-like friable hair is often the first sign of the disorder at 1–2 months of life. Macrognathia, prominent cheeks, pale skin, and frontal or occipital bossing may be present. Loose, dry skin may be seen. Failure to thrive, diarrhea, vomiting, and poor appetite may develop, and muscle tone may be abnormal. Urogenital abnormalities, such as bladder diverticula, can be seen. Radiographic findings include fractures, metaphyseal spurs, wormian bones, and tortuosity of the intracranial arteries. Children may have osteoporosis, leading to fractures, as well as pectus excavatum or carinatum. Vasculature is compromised, and at later stages of disease, subdural hemorrhages may occur. Blindness and

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Fig. 15 Two-year-old boy with Menkes Disease and the classic finding of dull, woollike, friable hair. (Photograph submitted by Stephen Messner, MD. Children’s Healthcare of Atlanta, Child Protection Team)

respiratory failure may occur as well (Amador et al. 2010; Tümer and Møller 2010) (Fig. 15).

Outcomes Children with AHT have poorer outcomes than children with accidental trauma (Keenan et al. 2004, Chen et al. 2019). They also have a higher need for neurosurgical intervention (Chen et al. 2019). Although long-term follow-up of families is difficult, a host of poor short-term and long-term outcomes have been found in children with abusive trauma (Keenan et al. 2004; Chen et al. 2019; Chevignard and Lind 2014). Poor short-term outcomes include a higher need for neurosurgical intervention, death with a mortality rate of approximately 25%, seizures, and cerebrovascular accident (CVA) (Chen et al. 2019, Keenan et al. 2004, Khan et al. 2017). A retrospective study of 292 children diagnosed with AHT over a 10-year period revealed that older age, or an initial GCS  5, predicted worse outcomes at hospital discharge (Chen et al. 2019). Adverse long-term outcomes in AHT are varied, affecting several systems. They include visual impairments (including blindness); microcephaly; cognitive deficits, including the need for early intervention services and special education; motor deficits, including paraplegia, hemiplegia, or quadriplegia; seizure disorder; behavior and sleep disorders, such as agitation, tantrums, aggression, attention deficits, memory impairments, inhibition deficits, and communication deficits. This combination of so many cognitive and intellectual deficits has a negative impact on academic achievement, with a high need for special education services among survivors of AHT (Keenan et al. 2004, Lind et al. 2016, Nuño et al. 2018). In summary, AHT is a condition with a high mortality rate and a high rate of severe short-term and long-term consequences, many of which have lifelong impact. Determination of the exact frequency of children with AHT who have adverse consequences is difficult to say with clarity, given the difficulties faced in performing long-term studies. However, in the studies which have been performed, well over half of the children in whom AHT was diagnosed had

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adverse long-term consequences (Keenan et al., 2004; Lind et al. 2016). Children with AHT have many ongoing health care and education needs and require extended follow-up.

Prevention Prevention efforts related to AHT are often aimed at many of the possible mediating factors. Programs like Period of Purple Crying aim to educate parents about infant development and normalize typical infant behaviors, especially crying, which may increase once the infant is a couple months old. This is helpful in establishing appropriate expectations for parents that may be at risk for viewing their crying infant as having a problem or as a difficult baby. This could potentially inhibit their ability to bond appropriately with their child and could increase the risk for abuse. There have been AHT prevention programs, also aimed at parents during the perinatal period, which aim to educate parents specifically on the dangers of shaking. One successful program was the prevention program undertaken by Dias et al. that not only set out to provide education to parents regarding AHT, but also sought to establish a contract with parents by having them voluntarily sign a commitment statement. The commitment statement documented their acknowledgement of the information provided and the fact that “violent shaking is harmful and potentially deadly to a baby.” One of the focuses of the study was making significant effort to identify and engage, whenever possible, fathers and father figures to be educated regarding the dangers of violent shaking. The study documented a 47% decrease in the incidence of abusive head trauma during the 5.5-year study period in a defined 8 county region of Western New York State (Dias et al. 2005). Although the study result was very positive, program replication has not been able to provide similar results. In the follow-up study, Dias et al. looked at data from birthing centers in Pennsylvania regarding the parents of infants born from January 2003 to December 2013. These parents read a brochure, viewed an 8-minute video about infant crying and abusive head trauma, discussed with the nurse, and signed a commitment statement. They looked at both hospitalization rates for abusive head trauma before and during the intervention in Pennsylvania and five other states. They also looked at parents’ “self-reported gains and changes in parenting practices.” The study found that the intervention was not associated with a reduction in the rate of AHT hospitalizations, but they did find that parents reported increased parental knowledge (Dias et al. 2017).

Conclusion When considering maltreatment across the lifespan, one must consider the impact of abusive head trauma. It is an especially impactful problem to the young, typically infants, who suffer the most serious sequela of AHT, including death. Young children bear the brunt of this particularly egregious and brutal trauma

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inflicted by their caregivers, often paying the price with their future well-being, and sometimes with their lives. As a medical community, it is important for us to consistently engage in a thoughtful and thorough evaluation of these cases to aid in their multidisciplinary management and, hopefully, move forward efforts to educate the community about this serious type of child abuse and the ways it can be prevented.

Key Points • Abusive Head Trauma (AHT) is one of the leading causes of death from child abuse in children younger than age two. • AHT occurs across all races, age groups, levels of education, perpetrator relationships, and levels of socioeconomic status. • Abusive head trauma can be caused by rotational injury to the brain via a contact mechanism, inertial forces, or a combination of both. • Common findings in abusive head trauma may include subdural hemorrhages, subarachnoid hemorrhages, retinal hemorrhages, hypoxic-ischemic injury, cortical vein thrombosis, and/or axonal injury around the craniocervical junction. • Children with suspicion for AHT should undergo head CT, MRI, or both. • Obtaining a detailed history is key and should include a detailed timeline of events prior to presentation and background information, such as past medical history, social history, and family history. • A dilated eye examination should be performed by a Pediatric Ophthalmologist in suspected AHT cases, preferably within 24 hours of presentation to the hospital. • Several different disease processes exist that may present with findings that are also seen in abusive head trauma. However, laboratory testing, radiologic findings, histories, and physical exams can differentiate these entities from AHT.

Cross-References ▶ Child Physical Abuse: A Pathway to Comprehensive Prevention ▶ Fractures ▶ Implications of Maltreatment for Young Children ▶ Parents Who Physically Abuse: Current Status and Future Directions

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Pierce, M. C., Kaczor, K., Aldridge, S., O’Flynn, J., & Lorenz, D. J. (2010). Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics, 125(1), 67–74. Rabbitt, A. L., Kelly, T. G., Yan, K., Zhang, J., Bretl, D. A., & Quijano, C. V. (2020). Characteristics associated with spine injury on magnetic resonance imaging in children evaluated for abusive head trauma. Pediatric Radiology, 50(1), 83–97. Reece, R. M., & Sege, R. (2000). Childhood head injuries: Accidental or inflicted? Archives of Pediatrics & Adolescent Medicine, 154(1), 11–15. Ríos, A., Casado-Flores, J., Porto, R., Jiménez, A. B., Jiménez, R., & Serrano, A. (2009). Maltrato infantil grave en la unidad de cuidados intensivos pediátricos. Anales de pediatria, 71(1), 64–67. Elsevier Doyma. Rooks, V. J., Eaton, J. P., Ruess, L., Petermann, G. W., Keck-Wherley, J., & Pedersen, R. C. (2008). Prevalence and evolution of intracranial hemorrhage in asymptomatic term infants. American Journal of Neuroradiology, 29(6), 1082–1089. Rorke-Adams, L. (2011). Neuropathology of abusive head trauma. In C. Jenny (Ed.), Child abuse and neglect: Diagnosis, treatment and evidence (pp. 349–358). St Louis: Saunders. Schulte, R., Jordan, L. C., Morad, A., Naftel, R. P., Wellons, J. C., III, & Sidonio, R. (2014). Rise in late onset vitamin K deficiency bleeding in young infants because of omission or refusal of prophylaxis at birth. Pediatric Neurology, 50(6), 564–568. Sheets, L. K., Leach, M. E., Koszewski, I. J., Lessmeier, A. M., Nugent, M., & Simpson, P. (2013). Sentinel injuries in infants evaluated for child physical abuse. Pediatrics, 131(4), 701–707. https://doi.org/10.1542/peds.2012-2780. Starling, S. P., Holden, J. R., & Jenny, C. (1995). Abusive head trauma: The relationship of perpetrators to their victims. Pediatrics, 95(2), 259–262. Starling, S. P., Patel, S., Burke, B. L., Sirotnak, A. P., Stronks, S., & Rosquist, P. (2004). Analysis of perpetrator admissions to inflicted traumatic brain injury in children. Archives of Pediatrics & Adolescent Medicine, 158(5), 454–458. Towner, D., Castro, M. A., Eby-Wilkens, E., & Gilbert, W. M. (1999). Effect of mode of delivery in nulliparous women on neonatal intracranial injury. New England Journal of Medicine, 341(23), 1709–1714. Tümer, Z., & Møller, L. B. (2010). Menkes disease. European Journal of Human Genetics, 18(5), 511–518. Vester, M. E., Bilo, R. A., Karst, W. A., Daams, J. G., Duijst, W. L., & Van Rijn, R. R. (2015). Subdural hematomas: Glutaric aciduria type 1 or abusive head trauma? A systematic review. Forensic Science, Medicine, and Pathology, 11(3), 405–415. Vester, M. E., Visser, G., Wijburg, F. A., van Spronsen, F. J., Williams, M., & van Rijn, R. R. (2016). Occurrence of subdural hematomas in Dutch glutaric aciduria type 1 patients. European Journal of Pediatrics, 175(7), 1001–1006. Wang, G., Zhang, Y. P., Gao, Z., Shields, L. B., Li, F., Chu, T., . . . Shields, C. B. (2018). Pathophysiological and behavioral deficits in developing mice following rotational acceleration-deceleration traumatic brain injury. Disease Models & Mechanisms, 11(1), dmm030387. Wittschieber, D., Karger, B., Pfeiffer, H., & Hahnemann, M. L. (2019). Understanding subdural collections in pediatric abusive head trauma. American Journal of Neuroradiology, 40(3), 388–395. Wright, J. N. (2017). CNS injuries in abusive head trauma. American Journal of Roentgenology, 208(5), 991–1001. Wright, J. N., Feyma, T. J., Ishak, G. E., Abeshaus, S., Metz, J. B., Brown, E. C., . . . Feldman, K. W. (2019). Subdural hemorrhage rebleeding in abused children: frequency, associations and clinical presentation. Pediatric Radiology, 49(13), 1762–1772.

Domestic Child Torture: Identifying Survivors and Seeking Justice

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Contents Understanding Domestic Child Torture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Torture – The Medical Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Improving the Identification of Child Torture Cases: CPS Investigations . . . . . . . . . . . . . . . . . Indicators That Can Signal Child Torture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Torture, Available Charges Do Not Fit the Crime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Model Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alabama . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alaska . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arizona . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arkansas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Colorado . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Connecticut . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Delaware . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . District of Columbia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Florida . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Georgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hawaii . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Idaho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Illinois . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Indiana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

407 407 408 408 410 418 420 422 424 424 425 425 425 426 426 426 427 427 428 428 429 429 429 430 430 430

This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. A. Ratnayake Macy (*) National Center for Child Abuse Statistics and Policy, Washington, DC, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_323

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Iowa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Kansas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Kentucky . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Louisiana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Maine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Maryland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Minnesota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mississippi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Missouri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Montana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nebraska . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nevada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New Hampshire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New Jersey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New Mexico . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New York . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . North Carolina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . North Dakota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ohio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Oklahoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Oregon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pennsylvania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rhode Island . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . South Carolina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . South Dakota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tennessee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Texas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Utah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vermont . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Virginia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Washington . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . West Virginia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wisconsin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wyoming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

431 431 432 432 433 433 434 434 435 435 436 436 437 437 438 438 438 439 439 439 440 440 441 441 441 441 442 442 443 444 444 444 445 445 446 447 447

Abstract

This chapter provides an overview of factors that can identify and differentiate child torture cases as high priority for child abuse investigators, prosecutors, and other child protection professionals. The chapter also explores these factors in the context of a case where the child protection system failed to save the life of a seven-year-old boy who disclosed allegations of abuse diagnostic of child torture. The chapter also discusses gaps in state criminal codes which allow perpetrators of child torture to potentially escape justice if the child survives. Keywords

Child torture · Severe and systemic abuse · CPS investigations · Child torture statutes · Model code

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Understanding Domestic Child Torture Introduction The first section of this chapter aims to help the reader differentiate between child torture and other forms of child abuse, and how to improve investigations to identify these cases. The second section of this chapter spotlights gaps within state criminal codes which may prevent the state from adequately seeking justice for a survivor of child torture. In 2017, the Turpin case in Perris, California, made headlines across the globe for the unthinkable conditions in which the 13 children were held. David and Louise Turpin tied their 13 children ages 2 to 29, up with ropes (ABC News, Perris torture case: Outline of accusations against Turpin parents (Jan 18, 2018), available at http://abc7.com/grisly-details-revealed-in-perris-childabuse-case/2968096/). When one child was able to escape, they used chains and padlocks to restrain the children to their beds (Id.). The Turpins frequently beat and even choked their children (Id.). They often did not release the children from their chains to go to the bathroom (Id.). David and Louise starved their biological children and even taunted them with food (Id.). The Turpins were charged with 12 counts of torture – one for each child with the exception of the youngest (ABC News, Perris torture case: Outline of accusations against Turpin parents (Jan 18, 2018), available at http://abc7.com/grisly-detailsrevealed-in-perris-child-abuse-case/2968096/). While other charges were also leveled against the parents, the torture charge with a potential sentence of up to a lifetime in prison is by far the most significant (Id.). California, Connecticut, Kentucky, and Michigan criminal codes contain a statute which designates torture as a crime that applies to both adult and child victims (See infra Part IV: State Criminal Codes (9–23). (red highlights).). Thirty-six states and DC have some form of child torture statute within its criminal code, but many of these statutes have significant loopholes. Fourteen state criminal codes have no form of child torture statute. The Turpin case made headlines across the globe, because thirteen children were held captive and tortured. An estimated 1–2% of children evaluated for child maltreatment by medical professionals fit the diagnostic criteria of child torture (Knox et al. 2014a). Child torture is distinct from the most commonly recognized abusive acts in severity, continuous nature, and intent of the perpetrator (Allasio & Fischer 1998). Child torture is usually prolonged or repeated and includes both severe psychological and physical cruelty designed to establish the perpetrator’s dominance and control over the victim’s psyche (Knox et al. 2014a). Victims suffer a severe combination of extreme physical and psychological maltreatment that involves intense humiliation and terrorization (Supra note 15 at 37.). Perpetrators of child torture often also do not seek medical attention for injuries resulting from the abuse or starvation they inflict on the child (Knox at 46.). Unlike less violent forms of abuse, it does not result from the perpetrator’s episodic or unchecked anger toward the child (Id.).

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Child Torture – The Medical Definition In February of 2014, Knox et al., a team of leading pediatricians, published Child Torture as a Form of Child Abuse in the Journal of Adolescent Trauma with the intent of developing a coherent medical definition. The team selected 28 cases to illustrate the phenomenon of severe and systematic abuse that is often misunderstood (Id. at 37.). Every child included in the study was the victim of more than one type of psychological abuse (Id. at 39.). At time of medical intervention or death, 93% of the children in the study had healing wounds signaling physical abuse; 89% had been isolated from people outside of the immediate family; 89% had been deprived of food; 79% had been deprived of water; 64% were restricted from performing normal bodily functions such as using the restroom; 61% had been physically restrained; and 21% had fractures (Id. at 39.). Death threats were made to 32% of the children in the study (Id. at 39.). The doctors excluded cases involving sexual torture based on the understanding that the perpetrator(s) motivation were different in cases of sexual torture (Id.). Based on the similarities found among these children, the authors proposed defining child torture for medical purposes as a longitudinal experience characterized by at least four repeated forms of maltreatment: at least two physical assaults, and two or more forms of psychological maltreatment (such as terrorizing and death threats) resulting in prolonged suffering, permanent disfigurement/dysfunction, or death. Child torture can be thought of as a combination of two or more cruel and inhuman treatments for protracted periods of time, such as: • • • • • • • • • •

Intentionally starving the child. Intentionally dehydrating the child. Intentionally withholding restroom facilities. Terrorizing and/or subjecting the child to death threats, Binding or restraining the child with ropes or electronic surveillance. Repeatedly physically or sexually abusing the child. Exposing the child to extreme temperatures without adequate clothing. Locking the child in closets or other small spaces. Forcing the child to eat excrement, or have sexual contact with animals. Forcing the child into odd and/or painful regimes of physical discipline designed to break the child’s will resulting in prolonged suffering, permanent disfigurement/dysfunction, or death.

Improving the Identification of Child Torture Cases: CPS Investigations Torture includes extreme forms of discipline, including intentionally limiting access to toilet, food, sleep, or other necessities which dehumanize or demean the child (Id.). However, these extreme forms of discipline are not always obvious during the

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initial investigation of a report of child abuse. Half of the children in the Knox study had been reported to Child Protective Services (“CPS”) (Id.). CPS investigators often accepted the caretaker’s explanation that the child was “the problem child” and emotionally/physically disturbed (Id.). Furthermore, more than one-quarter (27.3%) of the child abuse fatalities in the United States had at least one prior CPS contact in the 3 years prior to the date of death (U.S Dep’t Health and Human Services, Child Maltreatment 2017, 59 (Jan 2019).). Especially, as national child welfare policy is moving further toward limiting separation between child and caregiver, and providing services instead (Transcript: Acting Commissioner, Administration on Children Youth and Families Jerry Milner, Transforming Child Welfare: Closing Remarks, 21st Conference on Child Abuse and Neglect (April 26, 2019) (“moving the system away from separating families), available at, https://nccan.acf.hhs.gov/pdfs/transcript-milner-closing.pdf; See. Family First Prevention Services Act of 2018 Transforms Fostercare System, (https://www.usatoday.com/story/news/nation/2018/05/05/foster-care-family-first-pre vention-services-act-trump/573560002/; See Am. Bar Ass’n, Family Integrity and Family Unity Policy, 3, (2019) (All three developments – federal family separation litigation, the Family First Act, and new federal funding to support child and parent counsel – are unified around a theme of promoting family integrity and family connection for children and youth), available at, https://www.americanbar.org/con tent/dam/aba/directories/policy/annual-2019/118-annual-2019.pdf), the importance of distinguishing these cases are often life or death decisions. Reports of types of abuse indicative of child torture should be investigated with a traditional multidisciplinary team approach with victim centered practices – trust but verify what the child discloses through investigation and corroboration, rather than a collaborative approach of creating a friendly relationship between the investigators and the caregivers who are the alleged perpetrators of abuse (See. U.S. Dep’t of Health and Human Services, Differential Response in Child Protective Services, (accessed Jan 2020), available at, https://www.childwelfare.gov/organizations/? CWIGFunctionsaction¼rols:main.dspList&rolType¼Custom&RS_ID¼26). Investigating these cases is difficult. Children who are severely abused may be afraid to speak about what happens to him or her, or the abuse may be a part of his or her normal routine. The child may not give truthful answers or answer at all. If red flags related to child torture exist, conduct a thorough investigation to determine whether the child may be subject to other types of victimization as well. If the abuse is indicative of torture, leaving the child in the home may result in death.

Failure to Protect Case Example – Adrian Jones On July 8, 2013, Adrian Jones – a five-year-old little boy with light in his eyes and a heartwarming smile, told the Missouri Department of Social Services (MoDss) worker – H. Mills, and a police officer, his daddy hit him so hard “a little bone come out”; “my daddy keeps hitting me in the head and punches me in the stomach; and my mom keeps pulling on my ears and it really hurts,” “mommy and daddy locked me in a room by myself; mommy and daddy can’t feed me.” (Laura Bauer, Records: Adrian Jones told Missouri Investigators He Was Being Abused, KAN. CITY STAR, May 11, 2017, available at, https://www.kansascity.com/news/local/crime/

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article149893682.html; Complaint, Estate of Adrian Jones v. Kansas Dep’t of Children & Family, No. 1716-CV20855 15–18 (MO Cir. Ct., Aug. 27, 2017), available at https://www.scribd.com/document/373066551/2017-Adrian-JonesFamily-Lawsuit) He also told them, that his parents were mean to him when he talked about food and sometimes, he sleeps without a blanket and pillow, and they would lock him in a closet some nights. As part of the investigation, Adrian was taken to the local Children’s Advocacy Center, where he spoke with a forensic interviewer and disclosed being locked in his room, and the physical abuse by his parents. The parents, Heather and Michael Jones, denied they had abused the children. They said they both had military backgrounds and disciplined their children accordingly, which included forcing the children to do pushups, jumping jacks, and standing in the corner (Id.). Heather Jones told the MoDss worker that physicians gave the advice to lock Adrian in his room to keep the other children safe, because Adrian threatened to kill her and his sisters, and had even tried to start fires in the bathroom using lighter fluid (Id.). She also stated that Adrian had been hospitalized twice and suffered from unspecified mental issues (Id.).

Indicators That Can Signal Child Torture Cases of child torture do not occur instantaneously, but escalate over a period of months or years. Understanding that clusters of indicators can be diagnostic of child torture and potential risk of death is important to investigations. All cases of child torture include more than one form of abuse (Turner et al. 2010; Finkelhor et al. 2007.), though some forms of victimization are easier to identify than others. Clusters of indicators can signal child torture and that a case warrants deeper investigation, and potential removal. Two or more of the following cruel or unusual treatments signal child torture: (a) series of serious physical assaults; (b) intentionally depriving life’s necessities – food, water, restroom – from the child; (c) isolation, withdrawal from activities, deprivation of human contact through surveillance equipment or restraints, and or confinement; (d) odd and/or painful regimes of discipline intended to break the will of the child. Multiple reports of abuse from different hotline callers are also patterns that exist in these cases. Adrian’s account made on July 8, 2018, include serious serial physical abuse, withholding food, isolating him from the rest of the family in a small closet without a blanket or pillow, and the file includes numerous report of past abuse. The account should have set off alarm bells within investigators.

Multiple Reports of Child Abuse The July 2013 investigation was the second investigation in response to Missouri child abuse hotline calls (Id.). A previous call to the child abuse hotline in March of 2013 had reported that Adrian was being mistreated and all of the children lived in a filthy environment. MoDss found the abuse unsubstantiated on the March 2013 call. In July, the anonymous caller stated “the mom beats the living daylights out of her kids for no reason, and the mom sells meth out of her home.” Prior to the Missouri

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calls, there had been four reports of abuse to the child abuse hotline in Kansas where the Jones lived prior to moving to Missouri. During the second investigation in Missouri (the July 13th investigation) the Kansas records were available to the MoDss investigators. At the start of a new investigation, in-depth information from the reporter who called the tip line can help determine possible sources of information about the family that will help evaluate the past and current allegations of abuse, as well as help effectively plan the investigation (Donna Pence & Charles Wilson, The Role of Law Enforcement in the Response to Child Abuse and Neglect 13 (U.S. Dep’t of Health and Human Services, Nat’l Center on Child Abuse & Neglect 1992) (While this manual is older it is one of the better tools – well written, easy to understand, with evidence based practices – available related to child abuse investigations).). If the reporter of abuse is identified, interview the reporter. A pattern observed in child torture cases is multiple reports of child abuse. Often when a child is being severely abused, multiple adults who see the abuse will call child protective services potentially more than one time. Consequently, Dr. Emily Putnam-Hornstien at the Center for Social Service Research at UC Berkley published a study in the journal Child Maltreatment which linked data of over 4.3 million children born in California between 1999 and 2006. The research created a longitudinal record of child maltreatment allegations and death (Putnam-Hornstien 2011). The study found that after adjusting for risk factors at birth, children with a prior allegation of maltreatment died from intentional injuries at a rate that was 5.9 times greater than unreported children (Id.). Multiple calls from different callers reporting abuse can signal a dangerous situation that warrants a deep investigation, and potential removal. The families may also move across either county lines or state lines once a CPS investigation is opened to avoid the investigation and/or required services. Following up and determining whether child abuse was reported in other jurisdictions prior to the current one can provide insight. Currently, state child maltreatment case management systems do not connect over state jurisdictional boundaries. However, if severe abuse is suspected, reaching out across a state line or county line where the child lived prior could corroborate a pattern of abuse which is a signifier of danger.

Series of Serious Physical Assaults During the July 8, 2013, interview, Adrian stated, “my daddy keeps hitting me in the head and punches me in the stomach and my mom keeps pulling on my ears and it really hurts.” (Laura Bauer, Records: Adrian Jones told Missouri Investigators He Was Being Abused, KAN. CITY STAR, May 11, 2017, available at, https://www.kansascity. com/news/local/crime/article149893682.html; Complaint, Estate of Adrian Jones v. Kansas Dep’t of Children & Family, No. 1716-CV20855 15–18 (MO Cir. Ct., Aug. 27, 2017), available at https://www.scribd.com/document/373066551/2017-AdrianJones-Family-Lawsuit). Physical injuries can often be the most overt signal that non-accidental trauma occurred and/or is occurring. Physical assaults can include: “hitting, kicking, impacting against objects, beating with objects, tying, binding, gagging, stabbing or cutting, burning, breaking bones, exposure to prolonged environmental heat or

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cold, prolonged forced exercise, forced restraint in or maintenance of an uncomfortable position, forced ingestion of noxious fluids, dangerous materials or excrement, aggravating the pain of prior injuries.” (Knox et al. 2014b) Documentation For younger children who cannot speak, certain types of injuries called sentinel injuries such as rib fracture(s), abdominal trauma, and intracranial hemorrhage are highly correlated with child abuse (Lindberg et al. 2015). The assistance of a pediatrician can help determine whether an injury may or may not be accidental. In Adrian’s case, at 4 years old, he was old enough to speak – and told the MoDss investigator that his parents injured him. Visiting the home is essential, generally on an unannounced basis (Donna Pence & Charles Wilson, The Role of Law Enforcement in the Response to Child Abuse and Neglect 17–31 (U.S. Dep’t of Health and Human Services, Nat’l Center on Child Abuse & Neglect 1992)). Explain to the caregiver that CPS received a call concerning the child, and the purpose is to speak to the caregiver about the child’s condition – avoid using the term child abuse (Id.). Some parents admit to disciplining the child in a way that accidently caused severe injury, but they may not view it as child abuse (Id.). If the child sustained life-threatening injuries, the first priority is securing medical attention for the child. If the child is old enough, explain who the investigator is and what he or she will be doing (Id.). The caregiver should not be present during the interview with the child (Id.). Ask to speak with the child and develop a rapport. Establish the child’s developmental level; the child’s explanation of injury; who the child thinks is the caregiver; how the child is disciplined; how other children in the home are disciplined; how often the child and/or siblings have been injured in the past; what type of weapon or implement was used, and where it is now; and clothing the child was wearing (Id.). Visually examine the child for any injuries noted, and photograph areas of injuries or questionable findings (Id.). If reasonable, photograph the bruising on two different dates (Victor Vieth, When the Child Has Spoken: Corroborating the Forensic Interview, 5 Center Piece, Vol. 2, at 2 (Nat’l Child Protection Training Cent. 2010), available at, https://www.zeroabuseproject.org/wp-content/uploads/2019/02/ 472d771e-centerpiece-vol-2-issue-5.pdf). Bruises may change color or shape and may more accurately reflect the nature of an attack a day later rather than the first day (Id. at 1.). Also photograph the scene in which the abuse occurred, and any details the child stated that can be located (Id.). When corroborating the child’s statement, think at the child’s developmental level (Victor Vieth, Picture This: Photographing a Child Sexual Abuse Scene, 5 Center Piece, Vol.1, (Nat’l Child Protection Training Cent. 2010), available at, https://www.zeroabuseproject.org/wp-content/uploads/2019/02/ 472d771e-centerpiece-vol-1-issue-5.pdf). Children do not have a technical vocabulary to describe abuse, and may use unconventional words such as “pink snake” to describe a dildo, or “grandpa’s pee-pee throwing up” to describe ejaculation (Id. at 1–4.). Children often do not give specific details – for example, a child said she was abused “where there was a giant eagle”; the investigation later documented a large eagle on the bedspread of the room she was abused (Id. at 1–4.).

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Photographing the scene can help corroborate key aspects of the child’s statement and send the message to the victim that the investigator is taking the allegation of abuse seriously (Id. at 1–4.). Furthermore, photographs help refresh recollection, and can bring light to these events at a later date (Id. at 1–4.). If the case is severe enough to warrant criminal prosecution, the crime scene photos may be relevant to prove elements of the crime, give jurors perspective into the child and highlight the inability of the child to protect him or herself (Id. at 1–4.). Interview the caregiver separately. Remain nonjudgmental and ask for explanation of the injuries (Donna Pence & Charles Wilson, The Role of Law Enforcement in the Response to Child Abuse and Neglect 17–31 (U.S. Dep’t of Health and Human Services, Nat’l Center on Child Abuse & Neglect 1992).). The caregiver may not understand the impropriety of the physical abuse and may disclose (Id.). If anyone else was present, obtain a timeline for who cared for the child, during what periods, and who was present (Id.). If any question exists as to who is responsible for the abuse, ask when the caregiver first saw the injuries. Interview other caregivers, siblings, and neighbors (Id.). In some cases, corporal punishment or serious physical abuse may be justified by the perpetrator using scripture (See. Vieth 2014; Victor Vieth & Basyle Tchivdijan, When The Child Abuser Has a Bible: Investigating Child Maltreatment Sanctioned or Condoned by a Religious Leader, 12 Center Piece, no. 2, (Nat’l Child Protection Training Cent. 2010); Bottoms et al. (2004)). Understanding the biblical basis for corporal punishment including the extreme interpretations, moderate interpretations, and culturally sensitive practices could be helpful to the investigation of the case (Knox et al. 2014b). If abuse is indicated, it becomes vital to conduct a forensic interview quickly, because there is only a meaningful window of time before significant evidence is lost, and the ability to protect the child becomes inhibited (Victor Vieth, When the Child Has Spoken: Corroborating the Forensic Interview, 5 Center Piece, Vol. 2, at 2 (Nat’l Child Protection Training Cent. 2010), available at, https://www.zeroabuseproject.org/wp-content/uploads/2019/02/ 472d771e-centerpiece-vol-2-issue-5.pdf). In Adrian’s case, he described serial physical abuse at times which was severe enough to cause a “bone to come out of his head.” Adrian was taken to the Child Advocacy Center for an interview which was the right step.

Intentionally Depriving Life’s Necessities (Food, Water, Restroom) from the Child In addition to the serious physical abuse, Adrian spoke of his parents being mean to him at meals, and telling him they could not feed him, during the July 2013 interview. From that point, further inquiring about his mealtime would have been advisable – to determine whether his mealtime was different from others’ in the home. Complaints of excessive hunger or thirst should be taken seriously. Often these children attempt to steal food or water from the home or ask for food or water from others, and are severely punished if caught (Knox et al. 2014c). Perpetrators may hide the devastation of intentional starvation with layers of clothing. Unfortunately, investigators often base evaluations related to maltreatment solely on the history given by the authority figure perpetrating abuse conditions,  such as reports of

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eating disorders or other medical issues and fail to ask further questions to determine whether the starvation could be intentional (Id.). Asking open-ended questions such as “tell me about mealtime” is recommended (Id.). Extreme deprivation is often accepted as normal by the child, and asking openended questions allows to better illuminate the situation (Id.). Also ask if the child’s mealtime is different than other family members (Id.). Ask siblings if the reported child has different mealtime routines (Id.). Documentation In cases involving starvation, obtain laboratory studies for dehydration and nutritional status as soon as possible (Id. at 47.). Serial photographs of the victim from the time of removal until nutritional recovery are compelling to illustrate the severity of nutritional deprivation (Id.). Likewise, these children’s appetites and rapid weight gain after they are allowed food and fluids can aid in rebutting allegations that they suffer from eating disorders, and unusual endocrine systems. These cases can be distinguished from cases that are not intentional. Photographs should be taken to document the availability of sufficient food in the household (Id. at 46.). Additionally, photographs should also be taken of any objects of value in the home (e.g., latest technology, jewelry, alcohol, expensive shoes or clothing) to document the availability of resources in the home that could have been used to purchase food for the children (Id.). Signs of intentional starvation are a tremendous red flag that suggests other possible forms of victimization may also exist, and a very thorough investigation is necessary.

Isolation, Withdrawal from Activities, Deprivation of Human Contact through Surveillance Equipment or Restraints, and or Confinement During the July interview, Adrian had mentioned that he was confined into a closet without a pillow and blanket. Forced isolation is often observed in torture cases (Id. at 46.). The child or children may be removed from school and or outside activities, restricted from peer contact, imprisoned in barren or tightly confined spaces, either using restraints, or surveillance equipment to monitor activity (Id. at 44.). A pattern often seen in child torture cases is a scenario, where the victim(s) are withdrawn from school after a report of abuse from a teacher. A distinguishing factor in cases of child torture is that the victim is not educated after withdrawal from school and the withdrawal is done with the intent of isolating the child from observation. Once this information is obtained, it is critical to observe that space. Ask the parent, caregiver, or other authority figure to see the education worksheets, lesson plans, books, and materials by which the authority figure is teaching the child or children (See. Id.). Ask the child questions, such as “Where do you spend most of the day?” Also observe to see whether the space the child lives has photos, or any personal items that belong to the child. After isolation is achieved, the severe abuse often escalates to torture. Deprivation from human contact can also be achieved through electronic surveillance equipment to monitor the actions of the child victim. Ask the authority figure if there is surveillance equipment in the home, and if it exists, how it is used. Restraints

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or the victim being forced into tightly confined spaces is another pattern associated with child torture cases. Often the victim is confined without free access to toilet or water. Asking questions such as “tell me about going to the bathroom,” “what are the rules about sleep or potty,” or “where do you sleep?” can be very helpful in eliciting otherwise normalized routines (Id. at 47.). Documentation Photographs should be taken of where and how the victim is isolated – photos of the rooms, closets, cages, etc., along with measurements of the spaces where victim is confined. Also document other family member’s living conditions. The victim’s living conditions can be distinguished from other family members whose living quarters that did not include, locks, alarms, restraints, cages, confinement, or limited access to food or toilet.

Odd and/or Painful Regimes of Physical Discipline Intended to Break the Will of the Child During the July 13th investigation, Adrian’s caretakers offered that they disciplined their children by forcing the children to do pushups, jumping jacks, and standing in the corner. While this behavior may seem innocuous, combined with the other cruel and unusual punishments, this kind of discipline forced for significant periods of time could signal torture, in conjunction with other indicators. Another pattern observed in cases of abuse which have escalated to torture is odd, extreme, and potentially painful regimes of discipline. It is also critical in the investigation to discover the extent to which caregivers have created a system of rules, boundaries, and patterns for managing the targeted victim(s) which is unique. For example, a torturer in Wisconsin required an emaciated five-year-old child to walk laps with a heavily weighted backpack, and flippers prior to being able to eat small amounts of food (Samantha Hernandez, Father Sentenced To Jail In Wrightstown Child Abuse, Starvation Case (Green Bay Press Gazzette Jun 25, 2018) (120 Days In Jail), available at, Https://Www.Greenbaypressgazette.Com/Story/News/2018/06/25/ Bradley-Fahrenkrug-Sentenced-Jail-Child-Abuse-Starvation-Case/732203002/). In a case out of Iowa, the perpetrator required the emaciated child to walk laps around the house in the hot summer sun without access to water, carrying a heavy weight (Associated Press, Iowa Woman Filmed Torture Of Boyfriend’s 8-Year-Old Son Who Was Locked In Basement (Feb 6, 2019) (Less Than 1 Year In Jail), available at, Https://Ktla.Com/2019/02/06/Iowa-Woman-Filmed-Torture-Confinement-Of-Boy friends-8-Year-Old-Son-Prosecutor-Says/.). In New Jersey, a perpetrator required the children to stand at a particular stair in the same position for hours of the day (Oprah Winfrey Show, The Four Young Brothers Nearly Starved To Death By Their Own Parents(2010) (2 Years In Jail), available at, Https://Www.Youtube.Com/Watch? V¼H19jsatqzwq.). In Iowa, a perpetrator required the children to maintain squats and do pushups for stealing food (Tyler J. Davis, Attorneys Request Deferred Judgements For Iowa Parents (May 14, 2019) (2 Years Probation), available at, Https:// Www.Desmoinesregister.Com/Story/News/Crime-And-Courts/2019/05/14/IowaCrime-Child-Abuse-Kenny-Kelly-Fry-Osceola-Neglect-Child-Endangerment-Depart ment-Human-Services/3671331002/). In a case from New York, the perpetrators

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required the child to run laps with a car chasing her (Rochester First.Com, Staff Writer, 3 Charged With Torture Of Oswego County Child (Aug 31, 2017) (Main Perpetrator Received 2 Year Afford Plea), available at, Https://Www.Rochesterfirst.Com/News/ Local-News/3-Charged-With-Torture-Of-Oswego-County-Child/). In a case from Maryland, the children were forced to eat excrement (Rose Velazquez, Police: Maryland women locked up kids, made them eat dog feces (USA Today Jan 18, 2018) (39 years with 13-year sentence with 8 suspended resulting in 5 years in jail for torturing 3 children).). In cases such as these, the following investigative questions may be helpful: • • • •

“Do you ever get in trouble?” “Why do you get in trouble?” “What happens when you get in trouble?” “How long does it happen?”

Documentation Take photos of the items the victim(s) discuss. Take photos of the location in which the conduct happens. Corroborate date, time, and weather, and any specific details the victim mentions.

What Happened to Adrian Jones For Adrian’s case, the July 13 investigation was one that included a forensic interview, and partnership with the police department. However, the available records indicate that Adrian’s account was not necessarily believed. Adrian’s parents stated that Adrian had severe mental health problems and that the five-year-old was dangerous. Similar to the documented cases in the Knox study, the investigators seemed to believe Adrian’s parents. The investigators wanted the county juvenile system to take custody of Adrian (Laura Bauer, Records: Adrian Jones told Missouri Investigators He Was Being Abused, KAN. CITY STAR, May 11, 2017, available at, https://www.kansascity.com/news/local/crime/article149893682.html; Complaint, Estate of Adrian Jones v. Kansas Dep’t of Children & Family, No. 1716-CV20855 15–18 (MO Cir. Ct., Aug. 27, 2017), available at, https://www.scribd.com/document/ 373066551/2017-Adrian-Jones-Family-Lawsuit.). The juvenile officer suggested that given the child’s mental health concerns and the family being honest about locking him in the closet as a way to address this, the juvenile officer would prefer MoDss to develop a safety plan with the family and attempt Intensive In-Home Services (Id.). MCD found that by preponderance of evidence, Adrian had been neglected and attempted to provide intensive in-home services (Id.). K. Fewins from the MoDss provided the in-home-services. Within weeks, Heather and Michael Jones had stopped participating in services, and stated they were moving to Kansas (Id.).s The Missouri case was closed. Another MoDss worker S. Ragan made a call to the Kansas Department of Children and Family reporting the abuse in Missouri; she was informed the family still resided in Missouri. S. Ragan also reported that the children were homeschooled and not seen by any outside members of the family on a regular basis.

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On August 21, 2013, a concerned citizen made a phone call to the Missouri child abuse hotline – the third one – the person stated, Adrian “was not treated for medical issues, was locked in his room at night, and was targeted by his stepmom.” (Complaint, Estate of Adrian Jones v. Kansas Dep’t of Children & Family, No. 1716-CV20855 19 (MO Cir. Ct., Aug. 27, 2017), available at, https://www.scribd. com/document/373066551/2017-Adrian-Jones-Family-Lawsuit) Another MoDss case worker M. Wheeler investigated, and determined high risk, but did not open a case. On February 25, 2014, MoDss received – a fourth call – stating that Adrian’s father could not provide for Adrian’s medical care and he was vulnerable to abuse and neglect. MoDss caseworker A. Donnelly investigated. Adrian showed her a two inch line where Adrian told her, his father taped his arms and legs as punishment, and he was forced to stand in a corner. As a result of this visit, Heather and Michael Jones signed a voluntary placement agreement placing Adrian in the Family Guidance Center of St. Joseph North West Heath Services (FGC) for mental health treatment. MoDss worker M. Bruce supervised the placement agreement. The FGC diagnosed Adrian with post-traumatic stress disorder and he was placed with the Spofford Residential Treatment Center in Grandview, Jackson County, Missouri, from March 7, 2014, to September 4, 2014. Heather and Michael were required but refused to participate in Adrian’s treatment. Michael indicated he no longer wanted custody of Adrian. On August 28, 2014, a fifth call was placed to the MoDss hotline stating that Michael was unwilling to meet Adrian’s needs; MoDss placed Adrian at Spofford because of a child abuse hotline call; Adrian was diagnosed with post-traumatic stress disorder; Adrian was soon to be discharged from the residential treatment facility but Michael would not return calls; and Michael expressly stated that he would not follow up on outpatient appointments after Adrian is discharged. MoDss worker B. Burleson started an investigation on September 23, 2014. At this point, Adrian had been discharged to Michael and had been moved to Kansas. B. Burleson concluded the report did not meet the statutory definition of child abuse, and closed the case. In late 2015, during a domestic disturbance call to the Jones’s home in Kansas, police found the remains of seven-year-old Adrian Jones in a livestock pen (Jessica McMaster, Exclusive: Surveillance footage captures the last days of tortured KCK boy’s life (41: KSHB Kansas City News May 1, 2017), available at, https://www.kshb.com/longform/exclusive-surveillance-footage-captureslast-days-of-tortured-kck-boys-life). After the Jones arrest, Heather gave her iCloud account information to her landlord and asked her to save pictures of her children (Id.). The iCloud account showed that the house was under constant surveillance with cameras in every room monitoring Adrian’s movements (Id.). Adrian was forced to stand for hours with his hands in the air. He was strapped to a table and blindfolded (Id.). Someone cracks Adrian’s face open with a broomstick (Id.). He was not allowed to eat (Id.). Adrian spent his last days naked and locked in a shower stall for hours (Jessica McMaster, Exclusive: Surveillance footage captures the last days of tortured KCK boy’s life (41: KSHB Kansas City News May

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1, 2017), available at, https://www.kshb.com/longform/exclusive-surveillancefootage-captures-last-days-of-tortured-kck-boys-life). The Joneses forced him to stand in neck deep water in the family’s swimming pool overnight (Id.). Adrian was also tasered (Id.). After Adrian died in the shower stall, they left his body in there for weeks (Id.). Later the Jones threw his body into the livestock pen (Id.). Heather had uploaded notes about the abuse going back to 2012 (Id.). Indicators of torture were present during the July 13, 2013, investigation. The CPS records indicated escalating torture. Had the MoDss workers understood the diagnostic criteria of torture, properly investigated, and removed Adrian from the home, he may not have suffered and Adrian may have lived.

Child Torture, Available Charges Do Not Fit the Crime If the child survives torture, the state may be unable to obtain justice through the criminal justice system. Only California, Connecticut, Kentucky, and Michigan criminal codes contain a statute which designates torture as a crime that applies to both adult and child victims (See infra Appendix A: State Criminal Codes (16–35). (red highlights).). Sixteen other US criminal codes list torture as an element of child abuse statutes (See infra Appendix A: State Criminal Codes (16–35) (red highlights) (1. Alabama, 2. Delaware, 3. District of Columbia, 4. Florida, 5. Iowa, 6. Kansas 7. Mississippi, 8. New Mexico, 9. New Jersey. 10. Ohio, 11. Oklahoma, 12. South Dakota, 13. Tennessee, 14. Utah, 15. Virginia, 16. Washington, and 17. Wyoming).). An additional 17 states do not explicitly prohibit torture, but do prohibit (a) actions analogous to torture such as “causing extreme pain, “unusual cruelty,” “unjustifiable suffering”; (b) causing an injury to a child, and then defines that injury to include torture or analogous mental suffering element; or (c) a pattern of conduct that results in torture (See infra Appendix A: State Criminal Codes (16–35) (red highlights) (1. Colorado, 2. Georgia, 3. Idaho, 4. Louisiana, 5. Maryland, 6. Minnesota, 7. Missouri, 8. Nebraska, 9. Nevada, 10. New Jersey, 11. North Carolina, 12. North Dakota,13. Rhode Island, 14. Texas, 15. Vermont, and 16. Wisconsin).). Lastly, 14 state criminal codes do not contain any form of child torture statute (See infra Appendix A: State Criminal Codes (16–35) (red highlights) (1. Alaska 2. Arizona, 3. Arkansas, 4. Hawaii, 5. Illinois, 6. Indiana, 7. Maine, 8. Massachusetts, 9. Montana, 10. New Hampshire, 11. New York, 12. Oregon, 13. Pennsylvania, 14. West Virginia).). The 14 states that do not have a torture statute have a gap in their criminal statutory code. In these states, prosecutors must use charges such as felony assault, neglect, attempted murder, or misdemeanor endangerment that were not drafted to address the types of violence the victims endure. The lack of charges fitting the element of the crime can lead to injustice for survivors, early release for dangerous perpetrators, and the potential for the perpetrator to retain access to the survivor since foregoing reasonable reunification and termination of parental rights in most states requires severe charges of abuse (US. Dep’t Health & Human Services, Children’s

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Bureau, Reasonable Efforts to Preserve or Reunify the Family and Achieve Permanency for Children: State Statutes (2016).). To highlight the differences in state statutes, compare the 2011 Alaska case of the six James’ children to the Turpin case. Alaska does not have a torture statute. The six children were 13, 15, 18, 19, and two of who were 20 at the time of removal from the home (Lisa Demer & Richard Mauer, Anchorage woman charged with abuse of adopted kids, Anchorage News (May 18, 2011), available at, https://www.adn.com/ alaska-news/article/anchorage-woman-charged-abuse-adopted-kids/2011/05/18/). Anya James adopted the children over the course of a decade. Their bedrooms were downstairs in a converted garage with a concrete floor. James did not allow personal items in the rooms. The children were forced to use buckets instead of toilets (Id.). The doors and windows had alarms, and the rooms had audio and video equipment to track the children. The children were homeschooled and purposefully kept away from the world (Id.). During his victim impact statement, Tommy said, he went days without eating, and slept on a concrete floor in a 4-by-6-foot basement room (Id. Michelle Theriault Boots, In emotional hearing, former adopted children confront Hillside mother accused of abuse, Anchorage Daily News (Oct 24, 2017), available at, https:// www.adn.com/alaska-news/2017/10/24/in-emotional-sentencing-former-adoptivechildren-confront-hillside-mother-charged-with-abusing-them/). When his bones ached from the cold, he would perch precariously on a heater to sleep. His ankles were malformed from so much time spent curled into a ball for warmth (Id.). At age 18 when removed from the home, he only weighed 90 pounds (Id.). Tommy’s siblings were also severely malnourished. The youngest, who was 13, had to be hospitalized immediately and two others were bony and looked prepubescent even though they were 15 and 20 (Id.).s All three were covered by downy hair that is characteristic of starvation (Id.). When fed, the meal consisted mostly of beans or a mushy mix of oatmeal, mashed potatoes, and raw eggs (Id.). Anya James served the mixtures in small plastic containers without silverware. The siblings fought over the food and licked the containers clean (Michelle Theriault Boots, In emotional hearing, former adopted children confront Hillside mother accused of abuse, Anchorage Daily News (Oct 24, 2017), available at, https:// www.adn.com/alaska-news/2017/10/24/in-emotional-sentencing-former-adoptivechildren-confront-hillside-mother-charged-with-abusing-them/). Anya James told neighbors the victims were severely emotionally disturbed. She also took all the victims to the same psychiatrist and suggested diagnoses and medications (Id.). Anya James gave heavy doses of antipsychotics and tranquilizers to make the victims compliant (Id.). Four of the children tried to run away at various times (Id.). Each was returned to James, after James convinced police each child was disturbed (Id.). Originally, Anya James was charged with: • 10 counts of kidnapping: class A felony • 6 counts of first-degree assault by knowingly engaging in conduct that causes serious physical injury to a person: class A felony

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• 2 counts of endangering the welfare of a child by recklessly failing to provide an adequate quantity of food or liquids to a child, and causing protracted impairment of the child’s health: class C felony (Alaska vs. James, 3AN-11-05573CR, court records, available at, https://records.courts.alaska.gov/eaccess/search.page.6.1? x¼P8g7qK5QNHIhMWA*5oZlIyrsvZebmRdjtmN9iarrzR1av3aBbwuy7AW9E doe0PlCsZZDvfD0OajsAT3t2Hp*DA). After 6 years of court proceedings, in 2017, James plead guilty to two counts, endangering the welfare of a child, which roughly equated to 8 years in prison. However, James, wore an ankle monitor for six plus years of court proceedings, and was given credit for “time served” for the years of electronic monitoring. She will likely serve less than 2 years in jail. In the 2019 Turpin case, the parents each pled guilty to 12 counts of torture with each charge carrying a sentence of up to life in jail. They were sentenced to life in jail with the eligibility for parole after 25 years. After the Anya James’ sentencing, Tommy stated, “It’s not justice. Collectively we’ve had over 50 years taken from us. Fifty years of pain, collectively, between all the time each one of us spent.” For the 15 states without a child torture statute, this injustice is a pattern.

State Codes Even when cases of child torture are properly identified and documented, the justice system may not be able to charge the crime of child torture adequately. For example, Alaska, Arizona, Arkansas, Hawaii, Illinois, Indiana, Maine, Massachusetts, Montana, New Hampshire, New York, Oregon, Pennsylvania, and West Virginia have no child torture statute. Thirty-six states and DC have some form of child torture statute within its criminal code. These statutes are wide-ranging and heterogeneous. A summary of each state code pertaining to child tortured is found in appendix A.

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Only California, Connecticut, Kentucky, and Michigan have stand-alone statutes that specifically criminalize torture against individuals both over and under the ages of 18 (Cal. Penal Code § 206 torture; Mich. Comp. Laws Serv. § 750.85 Torture; felony; penalty; definitions; element of crime; other laws.). The Michigan and California statutes carry a potential sentence of up to life in prison if a defendant is found guilty. Both have withstood claims of unconstitutionality (See Id.). Both address the dynamics of child torture described by the pediatric community and provide a sentence of up to life in prison if a perpetrator is found guilty. Both statutes protect domestic violence victims, the elderly, and other vulnerable adults as well as children (See e.g., People v. Riley, Nos. 295,838, 298,164, 2011 WL 4501765, at *1 (Mich. Ct. App. Sept. 29, 2011) (per curiam) (affirming defendant’s torture conviction for breaking into an elderly man’s home, punching him in the face so hard his dentures came out, leaving a shoe print on his face, tying him up, and beating him at length until he repeatedly lost consciousness); People v. Lachniet, No. 297836, 2011 WL 2859818, at *1 (Mich. Ct. App. July 19, 2011) (per curiam) (affirming defendant’s torture conviction for breaking into an elderly woman’s home, punching her repeatedly in the face until she lost consciousness, and tying her up with cords). See, e.g., People v. Massie, 48 Cal. Rptr. 3d 304, 308–09 (Ct. App. 2006) (upholding defendant’s torture conviction after he raped a stranger in her home, reacted with rage when she told him that Jesus loved him, used various methods to inflict pain, and acted over a long period of time, taking breaks in between); People v. Pre, 11 Cal. Rptr. 3d 739, 740–42 (Ct. App. 2004) (holding that the torture conviction was supported by evidence that defendant selected a woman unknown to him, forcibly entered into her apartment, attacked her viciously when she resisted, twice choked her into unconsciousness, and then intentionally inflicted great bodily injury and cruel and extreme pain by biting her while she was helpless and for no other apparent purpose than revenge or sadistic pleasure). See, e.g., People v. Alvarez, No. F066511, 2014 WL 5409070, at *1–2 (Cal. Ct. App. Oct. 24, 2014) (affirming defendant’s conviction of torture for beating his girlfriend repeatedly with his hands, feet, a shoe rack, and aluminum bat); People v. McCoy, 156 Cal. Rptr. 3d 382, 386, 388 (Ct. App. 2013) (affirming defendant’s conviction of torture for folding his girlfriend’s legs backwards over her head, breaking her back and leaving her a quadriplegic, shoving batteries in her rectum, and smearing feces on her face); People v. Hamlin, 89 Cal. Rptr. 3d 402, 411–13 (Ct. App. 2009) (affirming defendant’s conviction of torturing his wife and sentence of life in prison for a long history of physical abuse, including strangulation, threats with guns and a sword, hitting her with a taser, hitting her injured wrist with a metal pipe, and threatening to kill her unless she falsely confessed to molesting their children); People v. Burton, 49 Cal. Rptr. 3d 334, 336–37 (Ct. App. 2006) (affirming defendant’s conviction of torture of the mother of his children for permanently disfiguring her face with four deep cuts in the presence of their young sons); People v. Baker, 120 Cal. Rptr. 2d 313, 315–16 (Ct. App. 2002) (affirming defendant’s torture conviction for pouring gasoline over his wife and setting her on fire); People v. Hale, 88 Cal. Rptr. 2d 904, 908–09 (Ct.

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App. 1999) (affirming defendant’s torture conviction when he entered the victim’s bedroom at night, while the victim slept beside her three-year-old daughter, and struck victim twice in the face with a ball peen hammer, cracking a number of her teeth, splitting her lip, and cutting her under the eye, and then stayed and hid in the room to observe victim’s pain and terror); People v. Healy, 18 Cal. Rptr. 2d 274, 277 (Ct. App. 1993) (affirming defendant’s torture conviction when he told the victim she never had any real hardship in her life and that “he needed to create some hardship” to get her to listen to him and proceeded to beat the victim unprovoked, warning the victim not to make any noise during beatings for fear a neighbor would call police). See, e.g., Studier, 2015 WL 447408, at *1 (affirming defendant’s torture conviction based on an attack against his estranged wife, whom he had abused for years, in which he kicked open her door and assaulted her until dawn, striking her in the face, kicking her in the groin, choking her, threatening her with a steak knife, calling her a whore, and blaming her for the attack); People v. Hinton, No. 308019, 2013 WL 514870, at *1 (Mich. Ct. App. Feb. 12, 2013) (per curiam) (affirming defendant’s torture conviction when he committed sexual assault against his victim, peed in her mouth, made her put a beer bottle in her vagina, whipped her with a cord while naked, tied her to the bed, and gagged her while he left the house).). For states that do not have statutes addressing severe and systematic violence against children or severe loopholes within the statutes, Michigan Comp. Laws Serv. § 750.85 is a recommended guide for legislatures.

Model Code The text of the Michigan statute is similar to the California statute. However, the Michigan statute improves upon the California statute. For the California statute, in order for a perpetrator to commit torture, the perpetrator must also inflict great bodily injury. Great bodily injury means more than minor or moderate harm, but includes abrasions, cuts, and bruising (CALCRIM 810 – Torture (Pen. Code, § 206). (“Great bodily injury means significant or substantial physical injury. It is an injury that is greater than minor or moderate harm.”)8 People v. Pre (2004) 117 Cal.App.4th 413, 419. (“Section 206 does not require permanent, disabling, or disfiguring injuries; “[s] ection 206 only requires ‘great bodily injury as defined in Section 12022.70 ‘Abrasions, lacerations and bruising can constitute great bodily injury.’)). Under the Michigan statute, a person may inflict great bodily injury or severe mental pain or suffering. For example, the Michigan statute would encompass James’s actions of forcing the children to strip naked and use buckets instead of toilets in front of their siblings, starving them, and drugging them even though these actions left no marks on the children’s bodies. The Michigan statue also eliminates the purpose requirement of the California statue that torture be committed for “the purpose of revenge, extortion, persuasion, or for any sadistic purpose.” Instead, the Michigan statute requires that the victim be under the “custody and physical control of the perpetrator.” (Mich. Comp. Laws Serv. § 750.85 (2005)). “Custody or physical control” is defined as the forcible

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restriction of a person’s movements or forcible confinement of the person so as to interfere with that person’s liberty, without that person’s consent or without lawful authority.” Id. Michigan courts have ruled that a threat to kill the victim or another if the victim does not abide by the perpetrator’s demands could also constitute forcible constraint (People v. Studier, No. 317351, slip op. (Mich. Ct. App. 2015), https:// scholar.google.com/scholar_case?case¼17117557453317897301&q¼%22forcible +restriction%22++and+threat&hl¼en&as_sdt¼20006&as_vis¼1). The Michigan statute was drafted as an improved version of the California one. It both elaborates on definitions, strips unused language, and clarifies overall intent. For these reasons, legislators should look to the Michigan statute for criminal prosecution of these cases.

Michigan Comp. Laws Serv. 5 750.85 is a recommended guide for legislatures.

(1) A person who, with the intent to cause cruel or extreme physical or mental pain and suffering, inflicts great bodily injury or severe mental pain or suffering upon another person within his or her custody or physical control commits torture and is guilty of a felony punishable by imprisonment for life or any term of years. (2) As used in this section: (a) “Cruel” nears brutal, inhuman, sadistic, or that which torments. (b) “Custody or physical control” means the forcible restriction of a person’s movements or forcible confinement of the person so as to interfere with that person’s liberty, without that person’s consent or without lawful authority. (c) “Great bodily injury” means either of the following: (i) Serious impairment of a body function as that term is defined in section 58c of the Michigan vehicle code, 1949 PA 300, MCL 257.58c. (ii) One or more of the following conditions: internal injury, poisoning, serious burns or scalding, severe cuts, or multiple puncture wounds. (d) “Severe mental pain or suffering” means a mental injury that results in a substantial alteration of mental functioning that is manifested in a visibly demonstrable manner caused by or resulting from any of the following: (i) The intentional infliction or infliction of great bodily injury. (ii) The administration or application, or threatened administration or application, of mind-altering substances or other procedures calculated to disrupt the senses or the personality. (iii) The threat of imminent death. (iv) The threat that another person will imminently be subjected to death, great bodily injury, or the administration or application of mind-altering substances or other procedures calculated to disrupt the senses or personality. (3) Proof that a victim suffered pain is not an element of the crime under this section. (continued)

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Michigan Comp. Laws Serv. 5 750.85 is a recommended guide for legislatures. (continued)

(4) A conviction or sentence under this section does not preclude a conviction or sentence for a violation of any other law of this state arising from the same transaction.

Summary and Conclusion The first section of this chapter differentiated between child torture and other forms of child abuse, and explained how to improve investigations to identify these cases. The second section of this chapter spotlights gaps within state criminal codes which may prevent the state from adequately seeking justice for a survivor of child torture. For Adrian, an understanding of the dynamics of child torture and the necessity for removal in these cases came too late. In order to save severely abused children’s lives CPS investigators must understand the diagnostic indicators of child torture, thoroughly investigate these cases, and save children’s lives by removing them from the situation. If a child survives, Tommy James said it best at Ana James’s sentencing when she received 2 years in prison. Tommy stated, “It’s not justice.” For states without a child torture statute or those state criminal codes with significant loopholes, the Michigan statute allows the legal system to greatly improve the ability of the state to provide justice to victims of child torture. We must and can do better to identify children who are victims of child torture, and provide a measure of justice for survivors.

Key Points • Investigators are not currently educated on the definition of child torture and how to identify it. • Child torture cases are more dangerous than acts of sporadic physical harm against a child due to the systemic nature of the abuse. • Understanding that child torture cases are those cases that are the most serious, identifying these cases, and providing intervention will save lives. • Torture is separate and distinct enough from physical abuse to warrant felony criminal codes to address these cases. A separate criminal torture statute ensures that perpetrators do not evade justice due to loopholes in state laws that only

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address physical abuse, and potentially have access to children again. Michigan’s criminal torture statute is a model for other states.

Appendix A Alabama

State code Ala. Code § 26–15-3 torture, willful abuse, Etc., of child under 18 years of age by responsible Persona

Ala. Code § 26–15-3.1 aggravated child Abusea

Ala. Code § 26–15-3.1 aggravated child under the age of six Abusea

a

Relevant language A responsible person, as defined in Section 26–15-2, who shall torture, willfully abuse, cruelly beat, or otherwise willfully maltreat any child under the age of 18 years shall, on conviction, be guilty of a class C felony. A responsible person, as defined in Section 26-15-2, commits the crime of aggravated child abuse if he or she does any of the following: a. He or she violates the provisions of Section 26-15-3 by acts taking place on more than one occasion. A responsible person, as defined in section 26–15-2, commits the crime of aggravated child abuse of a child under the age of six if he or she does any of the following to a child under the age of 6 years: a. He or she violates the provisions of section 26–15-3 by acts taking place on more than two occasions. . . c. He or she violates the provisions of section 26–15-3 which causes serious physical injury, as defined in section 13A-1-2, to the child

Intent Level Willfully Class C felony

Willfully Class B felony

Sentences guideline At least 1 year, up to 10 years

At least 2 years to 20 years

Willfully Class A At least felony 10 years, up to 99 years to life

Available at, www.lawserver.com/law/state/alabama/al-code/alabama_code_26-15-3

Alaska N/A (Alaska Stat. §11.41.220(a)(1) & (3) (2014). Assault in the third degree (closest available statute according to Physical Child Abuse Penalties, NAT’L DIST. ATTORNEYS ASS’N (2014)))

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Arizona N/A (Ariz. Rev. Stat. Ann. §13–3623 (2014). Child or vulnerable adult abuse; emotional abuse; classification; exceptions; definition ((closest available statute according to Physical Child Abuse Penalties, NAT’L DIST. ATTORNEYS ASS’N (2014)))

Arkansas N/A (Ark. Code Ann. § 5–13-201 (2014). Battery in the first degree (((closest available statute according to Physical Child Abuse Penalties, NAT’L DIST. ATTORNEYS ASS’N (2014)))

California State code Cal. Penal code § 273a willful harm or injury to child; endangering person or health; punishment; conditions of probationa

Cal. Penal code § 206 tortureb

Relevant language (a) any person who, under circumstances or conditions likely to produce great bodily harm or death, willfully causes or permits any child to suffer, or inflicts thereon unjustifiable physical pain or mental suffering, or having the care or custody of any child, willfully causes or permits the person or health of that child to be injured, or willfully causes or permits that child to be placed in a situation where his or her person or health is endangered . . . Every person who, with the intent to cause cruel or extreme pain and suffering for the purpose of revenge, extortion, persuasion, or for any sadistic purpose, inflicts great bodily as defined in Section 12022.7 upon the person of another, is guilty of torture. The crime of torture does not require any proof that the victim suffered pain.

Intent

Level N/A

Sentence Imprisonment in a county jail not exceeding 1 year, or in the state prison for 2, 4, or 6 years

Intentionally

N/A

Term of life

a Available at, https://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode¼PEN& division¼&title¼9.&part¼1.&chapter¼2.&article¼ b Available at, https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum¼206.& lawCode¼PEN

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Colorado State code COLO. REV. STAT. §18–6401 child abusea

a

Relevant language (1)(a) A person commits child abuse if such person causes an injury to a child’s life or health, or permits a child to be unreasonably placed in a situation that poses a threat of injury to the child’s life or health, or engages in a continued pattern of conduct that results in malnourishment, lack of proper medical care, cruel punishment, mistreatment, or an accumulation of injuries that ultimately results in the death of a child or serious bodily injury to a child.

Intent Bodily injury results AND Criminal negligence, OR recklessly/ knowingly

Level Range: Class 2 to class 5 felony

Sentence 1 to 24 years

Available at, http://codes.findlaw.com/co/title-18-criminal-code/co-rev-st-sect-18-6-401.html

Connecticut State code Conn. Gen. Stat. Ann. § 53–20 cruelty to personsa

a

Relevant language (a) (1) any person who intentionally tortures, torments or cruelly or unlawfully punishes another person or intentionally deprives another person of necessary food, clothing, shelter or proper physical care shall be guilty of a class D felony.

Intent Intentionally

Level Class D felony

Sentence 1 to 5 years

Available at, https://law.justia.com/codes/connecticut/2015/title-53/chapter-939/section-53-20/

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Delaware State code Del. CodeState code relevant language intent LevelSentence . Tit. 11§ 1103Ba child abuse in the first degree

a

Relevant language A person is guilty of child abuse in the first degree when the person recklessly or intentionally causes serious physical injury to a child: (1) through an act of abuse and/or neglect of such child; or (2) when the person has engaged in a previous pattern of abuse and/ or neglect of such child. Child abuse in the first degree is a class B felony (1) "abuse” means causing any physical injury to a child through unjustified force as defined in § 468(1)(c) of this title, torture, negligent treatment, sexual abuse, exploitation, maltreatment, mistreatment or any means other than accident

Intent Intentionally or recklessly

Level Class B felony

Sentence 2 to 25 years imprisonment

Available at, http://delcode.delaware.gov/title11/c005/sc05/index.shtml

District of Columbia State code D.C. code § 22–1101 cruelty to children definition and penaltya

a

Relevant language (a) A person commits the crime of cruelty to children in the first degree if that person intentionally, knowingly, or recklessly tortures, beats, or otherwise willfully maltreats a child under 18 years of age or engages in conduct which creates a grave risk of bodily injury to a child, and thereby causes bodily injury.

Intent Intentionally, knowingly, recklessly

Level First degree felony

Available at, https://beta.code.dccouncil.us/dc/council/code/sections/22-1101.html

Sentence Imprisoned not more than 15 years

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Florida State code Fla. stat. § 827.03. Abuse, aggravated abuse, and neglect of a childa

a

Relevant language (a) “aggravated child abuse” occurs when a person: Commits aggravated battery on a child; . . . willfully tortures, maliciously punishes, or willfully and unlawfully cages a child; knowingly or willfully abuses a child and in so doing causes great bodily harm, permanent disability, or permanent disfigurement to the child.

Intent Level Willfully First degree felony

Sentence Imprisonment not exceeding 30 years

Available at, http://codes.findlaw.com/ga/title-16-crimes-and-offenses/ga-code-sect-16-5-70.html

Georgia State code Ga. Code Ann. 16–5-70 cruelty to children

Relevant language (a) A parent, guardian, or other person supervising the welfare of or having immediate charge or custody of a child under the age of 18 commits the offense of cruelty to children in the first degree when such person willfully deprives the child of necessary sustenance to the extent that the child’s health or Wellbeing is jeopardized. (b) any person commits the offense of cruelty to children in the first degree when such person maliciously causes a child under the age of 18 cruel or excessive physical or mental pain.

Intent Level Willfully, First maliciously degree felony

Sentence Imprisonment for not less than 5 or more than 20 years

Hawaii N/A (HAWAII Haw. Stat. § 709–906 (2014). Abuse of family or household members; penalty (first conviction minimum of 48 hours in jail; misdemeanor)) ((closest available statute according to Physical Child Abuse Penalties, NAT’L DIST. ATTORNEYS ASS’N (2014)).)

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Idaho State code Id. Code Ann. 18–1501. Injury to children

Relevant language (1) any person who, under circumstances or conditions likely to produce great bodily harm or death, willfully causes or permits any child to suffer, or inflicts thereon unjustifiable physical pain or mental suffering, or having the care or custody of any child, willfully causes or permits the person or health of such child to be injured, or willfully causes or permits such child to be placed in such situation that its person or health is endangered, is punishable by imprisonment in the county jail not exceeding one (1) year, or in the state prison for not less than one (1) year nor more than ten (10) years.

Intent Willfully

Level n/a

Sentence Not less than 1 year; not more than 10 years

Illinois N/A (720 Ill. Comp. Stat. § 5/12–3.05 (2014). Aggravated battery ((closest available statute according to Physical Child Abuse Penalties, NAT’L DIST. ATTORNEYS ASS’N (2014)).)

Indiana N/A (Ind. Code Ann. § 35–42–2-1. Battery (2014) (closest available statute according to Physical Child Abuse Penalties, NAT’L DIST. ATTORNEYS ASS’N (2014)).)

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Iowa State code Iowa code § 726.6 child endangermenta

a

Relevant language (a.) knowingly acts in a manner that creates a substantial risk to a child or minor’s physical, mental or emotional health or safety. (b) by an intentional act or series of intentional acts, uses unreasonable force, torture or cruelty that results in bodily injury, or that is intended to cause serious injury. (c.) by an intentional act or series of intentional acts, evidences unreasonable force, torture or cruelty which causes substantial mental or emotional harm to a child or minor.

Intent Knowingly, intentionally

Level A person who commits child endangerment resulting in serious injury to a child or minor is guilty of a class “C” felony.

Sentence Prison term of up to 10 years

Available at, https://law.justia.com/codes/iowa/2016/title-xvi/chapter-726/section-726.6/

Kansas State code Kan. Stat. § 21– 5602 abuse of a childa

a

Relevant language (a) Abuse of a child is knowingly:(1) torturing or cruelly beating any child under the age of 18 years; (2) shaking any child under the age of 18 years which results in great bodily harm to the child; or (3) inflicting cruel and inhuman corporal punishment upon any child under the age of 18 years. (b) abuse of a child is a severity level 5, person felony.

Intent Knowingly

Level Severity level 5

Sentence Between 31 and 136 months depending on past conviction history (2.5– 11.3 years)a

Available at, http://www.sentencing.ks.gov/docs/default-source/2017-forms/2017-nondrug-grid. pdf?sfvrsn¼0

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Kentucky State code Ky. Rev. stat. Ann. § criminal abuse in the first, 508.100a second, 508.110b, third degree, 508.120c

Relevant language 1) A person is guilty of criminal abuse in the first degree when he [intentionally, wantonly, recklessly] abuses another person or permits another person of whom he has actual custody to be abused and thereby: (a) causes serious physical injury; or (b) places him in a situation that may cause him serious physical injury; or (c) causes torture, cruel confinement or cruel punishment; to a person twelve (12) years of age or less, or who is physically helpless or mentally helpless.

Intent Category Intentionally Class C felony Wantonly Class D felony Recklessly Class A misdemeanor

Sentence Imprisonment 5–10 years Imprisonment 1–5 years Imprisonment 90 days to 12 months in jail (0.25 yrs. to 1 year)

a

Available at, http://www.lrc.ky.gov/Statutes/statute.aspx?id¼19740 Available at, http://www.lrc.ky.gov/Statutes/statute.aspx?id¼19741 c Available at, http://www.lrc.ky.gov/Statutes/statute.aspx?id¼19742 b

Louisiana State code La. Rev. stat. Ann. § 14:93 cruelty to juvenilesa

La. Rev. stat. Ann 14:93.2.3 – Second degree cruelty to juveniles

a

Relevant language (1) the intentional or criminally negligent mistreatment or neglect by anyone 17 years of age or older of any child under the age of seventeen whereby unjustifiable pain or suffering is caused to said child. Lack of knowledge of the child’s age shall not be a defense. . . (1) second degree cruelty to juveniles is the intentional or criminally negligent mistreatment or neglect by anyone over the age of seventeen to any child under the age of seventeen which causes serious bodily injury or neurological impairment to that child.

Available at, http://legis.la.gov/legis/Law.aspx?d¼78723

Intent Intentional or criminally negligent

Sentence No more than 10 years

Intentional or criminally negligent

Not more than 40 years

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Maine N/A (69Me. Rev. Stat. Ann. Tit. 17-A § 207-A (2014). Domestic violence assault (closest available statute according to Physical Child Abuse Penalties, NAT’L DIST. ATTORNEYS ASS’N (2014)).) State code Md. Code Ann. Crim. Law. § 3–601 (2019) child abuse

Relevant language (b) (2) “abuse” means physical injury sustained by a minor as a result of cruel or inhumane treatment or as a result of a malicious act under circumstances that indicate that the minor’s health or welfare is harmed or threatened by the treatment or act. (d1) i) A parent or other person who has a permanent or temporary care or custody or responsibility for the supervision of a minor may not cause abuse to the minor, (ii) A household member or family member may not cause abuse to the minor...[A] person who violets (1) of this subsection is guilty of the felony of child abuse in the second degree and on conviction is subject to the imprisonment not exceeding 15 years.

Intent N/A

Level Second degree felony

Sentences Up to 15 years

The statute does not define physical injury. A search of criminal cases did not lead to a definition of physical injury. Civil cases specifically define physical injury in the context of required injury for civil fraud. The civil definition of physical injury could be argued to apply in the criminal context as well. See Hoffman v. Stamper, 867 A. 2d 276 (Md. Ct. App.2005). “In Vance, we noted that, for purposes of applying the “modern rule,” the term “physical” was not used in its ordinary dictionary sense, but instead “is used to represent that the injury for which recovery is sought capable of objective determination.” Id. at 500, 408 A.2d at 733–34. In that reg rd, we observed that it has been held to include such things as depression, inability to work or perform routine household chores, loss of appitete, insomnia, nightmares, loss of weight, extreme nervousness and irritability, withdrawal from socialization, fainting, chest pains, headaches, and upset stomachs. Id. at 501, 408 A.2d at 734, and cases there.”

Maryland Insert text.

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Massachusetts N/A (Mass. Gen. Laws ann. Ch. 265 § 13 J (2014). Assault and battery upon a child; penalties (closest available statute according to Physical Child Abuse Penalties, NAT’L DIST. ATTORNEYS ASS’N (2014)).)

Michigan State code Mich. Comp. Laws § 750.136ba child abuse

Mich. Comp. Laws Serv. § 750.85b torture; felony; penalty; definitions; element of crime; other laws a

Relevant language (2) A person is guilty of child abuse in the first degree if the person knowingly or intentionally causes serious physical or serious mental harm to a child. (3) A person if guilty of child abuse in the second degree if any of the following apply: (a) the person’s omission causes serious physical harm or serious mental harm to a child or if the person’s reckless act causes serious physical harm or serious mental harm to a child. (b) the person knowingly or intentionally commits an act likely to cause serious physical or mental harm to a child regardless of whether harm results. (c) the person knowingly or intentionally commits an act that is cruel to a child regardless of whether harm results. (1) A person who, with the intent to cause cruel or extreme physical or mental pain and suffering, inflicts great bodily injury or severe mental pain or suffering upon another person within his or her custody or physical control commits torture and is guilty of a felony punishable by imprisonment for life or any term of years.

Intent Knowingly or intentionally

Level First degree

Recklessly, or knowingly or intentionally

Second degree

Intentionally

First degree

Sentence Life in jail or term of any years First offense not more than 10 years Second offense not more than 20 years

Life in jail or term of any years

Available at, http://www.legislature.mi.gov/(S(vdy114cxkisgijpoiwvgxnrv))/mileg.aspx? page¼GetObject&objectname¼mcl-750-136b b Available at, http://www.legislature.mi.gov/(S(pejfuayif4pt0xrxuobqzvpy))/mileg.aspx? page¼GetObject&objectname¼mcl-750-85

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Minnesota State code MINN. STAT. § 609.377a malicious punishment of child

a

Relevant language 1.A parent, legal guardian, or caretaker who, by an intentional act or a series of intentional acts with respect to a child, evidences unreasonable force or cruel discipline that is excessive under the circumstances is guilty of malicious punishment of a child and may be sentenced as provided in subdivisions 2

Intent Intentional

Level Misdemeanor to felony depending on level of serious bodily harm

Sentence No more than 10 years

Available at, https://www.revisor.mn.gov/statutes/?id=609.377

Mississippi State code Miss. Code Ann. §97–5-39a contributing to the neglect or delinquency of a child; felonious abuse and/or battery of a child a

Relevant language (a) whether bodily harm results or not, if the person shall intentionally, knowingly or recklessly: (ii) physically torture any child;

Intent Intentionally, knowingly, recklessly

Definition Sentence “Bodily harm” means Up to life any bodily injury to a imprisonment child and includes, but is not limited to, bruising, bleeding, lacerations, soft tissue swelling, and external or internal swelling of any body organ

Available at, https://law.justia.com/codes/mississippi/2016/title-97/chapter-5/section-97-5-39/

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Missouri State code Mo. Stat. § 568.060a abuse or neglect of child

a

Relevant language Intent 2. A person commits Knowingly the offense of abuse or neglect of a child if such person knowingly causes a child who is less than 18 years of age:(1) to suffer physical or mental injury as a result of abuse or neglect; or(2) to be placed in a situation in which the child may suffer physical or mental injury as the result of abuse or neglect. 5(1) to have been previously found guilty of a violation of this section or of a violation of the law of any other jurisdiction that prohibits the same or similar conduct increases penalty

Definition and level “Abuse,” the infliction of physical, sexual, or mental injury against a child by any person 18 years of age or older. “Mental injury,” an injury to the intellectual or psychological capacity or the emotional condition of a child as evidenced by an observable and substantial impairment of the ability of the child to function within his or her normal range of performance or behavior; “Physical injury,” physical pain, illness, or any impairment of physical condition, including but not limited to bruising, lacerations, hematomas, welts, or permanent or temporary disfigurement and impairment of any bodily function or organ... Class D felony (up to 7 years). 5(1) finding changes felony level to class B (5–15 years)

Sentence 1 year to 15 years depending on level of injury and child does not die

Available at, http://www.moga.mo.gov/mostatutes/chapters/chapText568.html

Montana N/A (Mont. Code § 45–5-201 (2014). Assault ((closest available statute according to Physical Child Abuse Penalties, NAT’L DIST. ATTORNEYS ASS’N (2014)).)

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Nebraska State code Neb. Rev. stat. § 28– 707a child abuse penalties

a

Relevant language (1) A person commits child abuse if he or she knowingly, intentionally, or negligently causes or permits a minor child to be: (a) placed in a situation that endangers his or her life or physical or mental health; (b) cruelly confined or cruelly punished; (c) deprived of necessary food, clothing, shelter, or care;

Intent Knowingly, intentionally, negligently knew or should have known of the danger and acted recklessly

Level/sentence Misdemeanor up to class II felony. Range: Not more than 1 year for lowest misdemeanor; not less than 1 year up to 50 years for class II felony depending on level of injury, and child does not die

Available at, http://nebraskalegislature.gov/laws/statutes.php?statute¼28-707

Nevada State code Nev. Rev. stat. § 200.508a abuse, neglect or endangerment of child

a

Relevant language (1) A person who willfully causes a child who is less than 18 years of age to suffer unjustifiable physical pain or mental suffering as a result of abuse or neglect or to be placed in a situation where the child may suffer physical pain or mental suffering as the result of abuse or neglect

Intent Willfully

Level If substantial bodilyb or mental harmc results to the child: Class B felony (see statute for full sentencing structure, also related to sexual abuse) If no substantial bodily or mental harm occur, lower prison time (1– 6 years); with previous convictions under this section (2– 15) if parent or legal guardian and child under 14 potentially higher penalty

Sentence 2–20 years

Available at, https://www.leg.state.nv.us/NRS/NRS-200.html#NRS200Sec508 “Substantial mental harm” means an injury to the intellectual or psychological capacity or the emotional condition of a child as evidenced by an observable and substantial impairment of the ability of the child to function within his or her normal range of performance or behavior c “Physical injury” means:(1) Permanent or temporary disfigurement; or (2) Impairment of any bodily function or organ of the body b

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New Hampshire N/A (N.H. Rev. Stat. § 631:2 Assault (2014). ((closest available statute according to Physical Child Abuse Penalties, NAT’L DIST. ATTORNEYS ASS’N (2014)).)

New Jersey State code N.J. STAT. ANN. § 9:6–1.a abuse, abandonment, cruelty and neglect of child; what constitutes

a

Relevant language Cruelty to a child shall consist in any of the following acts: (a) inflicting unnecessarily severe corporal punishment upon a child; (b) inflicting upon a child unnecessary suffering or pain, either mental or physical; (c) habitually tormenting, vexing or afflicting a child; (d) any willful act of omission or commission whereby unnecessary pain and suffering, whether mental or physical, is caused or permitted to be inflicted on a child

Intent Any person having a legal duty for the care of a child or who has assumed responsibility for the care of a child who engages in cruelty Willful act of omission or commission

Level Fourth degree

Sentence Up to 18 months (1.5 years)

Available at, https://law.justia.com/codes/new-jersey/2016/title-9/section-9-6-1/

New Mexico State code N.M. stat. § 30–6-1a abandonment or abuse of a child

a

Relevant language D. Abuse of a child consists of a person knowingly, intentionally or negligently, and without justifiable cause, causing or permitting a child to be:. . ..(2) tortured, cruelly confined or cruelly punished;

Intent Knowingly, intentionally, negligently

Level E. A person who commits abuse of a child that does not result in the child’s death or great bodily harm is, for a first offense, guilty of a third degree felony and for second and subsequent offenses is guilty of a second degree felony. If the abuse results in great bodily harm to the child, the person is guilty of a first degree felony

Sentence Third degree: Up to 3 years imprisonment Second degree: Up to 9 years imprisonment First degree: Up to 18 years imprisonment

Available at, https://law.justia.com/codes/new-mexico/2016/chapter-30/article-6/section-30-6-1/

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New York N/A (N.Y. Penal Law § 120.05 (2014). Assault ((closest available statute according to Physical Child Abuse Penalties, NAT’L DIST. ATTORNEYS ASS’N (2014)))

North Carolina State code N.C. gen. Stat. § 14– 318.4a child abuse a felony

Relevant language (a) A parent or any other person providing care to or supervision of a child less than 16 years of age who intentionally inflicts any serious bodily injuryb to the child or who intentionally commits an assault upon the child which results in any serious bodily injury to the child, or which results in permanent or protracted loss or impairment of any mental or emotional function of the child, is guilty of a class B2 felony.

Intent Intentionally

Level B2 felony

Sentence 94– 393 months (7.8 to 32.75 years) imprisonment

a

Available at, http://www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/BySection/Chapter_ 14/GS_14-318.4.html b Serious bodily injury. – Bodily injury that creates a substantial risk of death or that causes serious permanent disfigurement, coma, a permanent or protracted condition that causes extreme pain, or permanent or protracted loss or impairment of the function of any bodily member or organ, or that results in prolonged hospitalization

North Dakota State code N.D. cent. Code § 14–09-22a – Abuse of child – Penalty

a

Relevant language 1. Except as provided in subsection 2 or 3, a parent, adult family or household member, guardian, or other custodian of any child, who willfully inflicts or allows to be inflicted upon the child mental injury or bodily injury, substantial bodily injury, or serious bodily injury as defined by section 12.1–01-04 is guilty of a class C felony except if the victim of an offense under subdivision a is under the age of 6 years in which case the offense is a class B felony

Intent Willfully

Level Class C felony Class B felony

Sentence Maximum penalty 5 years imprisonment Maximum penalty 10 years imprisonment

Available at, https://www.lawserver.com/law/state/north-dakota/nd-code/north_dakota_code_14_ 09_22

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Ohio State code Ohio rev. code Ann. § 2919.22a endangering children.

Relevant language B. no person shall do any of the following to a child under 18 years of age or a mentally or physically handicapped child under 21 years of age:. . .(2) torture or cruelly abuse the childb. . .

Intent (B)(2) endangering children is a felony of the third degree. If the violation results in serious physical harmc to the child involved, or if the offender previously has been convicted of an offense under this section or of any offense involving neglect, abandonment, contributing to the delinquency of, or physical abuse of a child, endangering children is a felony of the second degree* additional penalties for sex trafficking

Level Third degree felony Second degree felony

Sentence 9 months to 3 years imprisonment 2–8 years imprisonment

a

Available at, http://codes.ohio.gov/orc/2919.22 Torture: ‘the infliction of severe pain or suffering (of body or mind) as defined in [State v. Wainscott, 12th Dist. Butler No. CA2015–07–056, 2016–Ohio–1153, 24, quoting State v. Surles, 9th Dist. Summit No. 23345, 2007–Ohio–6050, c Serious physical harm to persons” means any of the following: (a) Any mental illness or condition of such gravity as would normally require hospitalization or prolonged psychiatric treatment; (b) Any physical harm that carries a substantial risk of death; (c) Any physical harm that involves some permanent incapacity, whether partial or total, or that involves some temporary, substantial incapacity; (d) Any physical harm that involves some permanent disfigurement or that involves some temporary, serious disfigurement; (e) Any physical harm that involves acute pain of such duration as to result in substantial suffering or that involves any degree of prolonged or intractable pain. b

Oklahoma State code Okla. Stat. Tit. 21 Ann. § 843.5 (2014)1qa. Child abuse, child neglect, child sexual abuse, child sexual exploitation, enabling, Penaltiesa a

Relevant language A. “child abuse” means the willful or malicious harm or threatened harm or failure to protect from harm or threatened harm to the health, safety, or welfare of a child under eighteen (18) years of age by another, or the act of willfully or maliciously injuring, torturing or maiming a child under eighteen (18) years of age by another.

Intent Willfully, maliciously

Level Felony

Available at, https://law.justia.com/codes/oklahoma/2016/title-21/section-21-843.5/

Sentence County jail not exceeding 1 year, or Up to life in prison

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Oregon N/A (Or. Rev. Stat. § 163.205 (2014). Criminal mistreatment in the first degree – failure to protect ((closest available statute according to Physical Child Abuse Penalties, NAT’L DIST. ATTORNEYS ASS’N (2014)).)

Pennsylvania N/A (18 Pa. Cons. Stat. Ann. § 2701 (2014). Simple assault ((closest available statute according to Physical Child Abuse Penalties, NAT’L DIST. ATTORNEYS ASS’N (2014)).)

Rhode Island State code RI gen L § 11– 9-5.3

Relevant language ((b) whenever a person having care of a child, as defined by § 40–11–2(2), whether assumed voluntarily or because of a legal obligation, including any instance where a child has been placed by his or her parents, caretaker, or licensed or governmental child placement agency for care or treatment, knowingly or intentionally: (2) inflicts upon a child any other physical injury, shall be guilty of second degree child abuse. For the purpose of this section, “other physical injury” is defined as any injury arises other than from the imposition of nonexcessive corporal punishment.

Intent Intentionally/ knowingly

Level Second degree child abuse

Sentences 5–10 years

Level Nonspecific felony

Sentences 3–10 years

South Carolina State code S.C. CODE ANN. § 63– 5-70 unlawful conduct toward A child

Relevant language (A) It is unlawful for a person who has charge or custody of a child, or who is the parent or guardian of a child, or who is responsible for the welfare of a child as defined in Section 63–7-20 to: (1) place the child at unreasonable risk of harm affecting the child’s life, physical or mental health, or safety; (2) do or cause to be done unlawfully or maliciously any bodily harm to the child so that the life or health of the child is endangered or likely to be endangered. . .

Intent

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South Dakota State code SOUTH DAKOTAS.D. codified Laws § 26–10-1a abuse of or cruelty to minor

Relevant language Any person who abuses, exposes, tortures, torments, or cruelly punishes a minor in a manner which does not constitute aggravated assault, is guilty of a class 4 felony. If the victim is less than 7 years of age, the person is guilty of a class 3 felony.

Level Class 3 Class 4

Sentence Up to 15 years imprisonment Up to 10 years imprisonment

a Available at, http://sdlegislature.gov/Statutes/Codified_Laws/DisplayStatute.aspx? Type¼Statute&Statute¼26-10-1

Tennessee State code TENN. CODE ANN. § 39–15-402 aggravated child abuse and neglect

Relevant language (a) A person commits the offense of aggravated child abuse, aggravated child neglect or aggravated child endangerment, who commits..(3) the act of abuse, neglect or endangerment was especially heinous, atrocious or cruel, or involved the infliction of torture to the victim;

Intent N/A

Level Class B felony Class A felony if child under 8 or disabled

Sentences 8–30 years 15–60 years

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Texas State code Texas penal code § 22.04a Injury to a child, elderly individual, or disabled individual

a

Relevant language (a) A person commits an offense if he intentionally, knowingly, recklessly, or with criminal negligence, by act or intentionally, knowingly, or recklessly by omission, causes to a childb, elderly individualc, or disabled individuald: 1. Serious bodily injurye; 2. Serious mental deficiency, impairment, or injury; or, 3. Bodily injury.

Intent (e) an offense under subsection (a)(1) or (2) is a felony of the first degree when the conduct is committed intentionally or knowingly. When the conduct is engaged in recklessly, the offense is a felony of the second degree.

Level First degree felony Second degree felony

Sentence Imprisonment for life or for any term of not more than 99 years or less than 5 years Imprisonment for any term of not more than 20 years or less than 2 years

Available at, http://www.statutes.legis.state.tx.us/Docs/PE/htm/PE.22.htm “Child” means a person 14 years of age or younger c “Elderly individual” means a person 65 years of age or older d “Disabled individual” means a person: (A) with one or more of the following: (i) autism spectrum disorder, as defined by Section 1355.001, Insurance Code; (ii) developmental disability, as defined by Section 112.042, Human Resources Code; (iii) intellectual disability, as defined by Section 591.003, Health and Safety Code; (iv) severe emotional disturbance, as defined by Section 261.001, Family Code; or, (v) traumatic brain injury, as defined by Section 92.001, Health and Safety Code; or, (B) who otherwise by reason of age or physical or mental disease, defect, or injury is substantially unable to protect the person’s self from harm or to provide food, shelter, or medical care for the person’s self. e “Serious bodily injury” means bodily injury that creates a substantial risk of death or that causes death, serious permanent disfigurement, or protracted loss or impairment of the function of any bodily member or organ b

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Utah State code Utah Code Ann. § 76–5-109a Child abuse, Child abandonment

a

Relevant language (3) Any person who inflicts upon a child serious physical injury or, having the care or custody of such child, causes or permits another to inflict serious physical injury upon a child is guilty of an offense as follows (i) Serious physical injury” means any physical injury or set of injuries that: (A) seriously impairs the child’s health; (B) involves physical torture; (C) causes serious emotional harm to the child; or (D)involves a substantial risk of death to the child.

Intent 2(a)if done intentionally or knowingly, the offense is a felony of the second degree; 2(b)if done recklessly, the offense is a felony of the third degree; or 2(c)if done with criminal negligence, the offense is a class A misdemeanor.

Sentence Prison term of one to 15 years Prison term up to 5 years Prison term up to 1 year

Available at, https://le.utah.gov/xcode/Title76/Chapter5/76-5-S109.html

Vermont State code Vt. Stat. Ann. Tit. 13 § 1304a Cruelty to child a

Relevant language (a) A person over 16 years of age, having the custody, charge or care of a child, who willfully assaults, ill treats, neglects or abandons or exposes such child, or causes or procures such child to be assaulted, illtreated, neglected, abandoned or exposed, in a manner to cause such child unnecessary suffering,

Intent Willfully

Sentence Up to 2 years in prison

Available at, http://legislature.vermont.gov/statutes/section/13/025/01304

Virginia State code VA Stat § 40.1–103a Cruelty and injuries to children; penalty; abandoned infant

a

Relevant language A. It shall be unlawful for any person employing or having the custody of any child willfully or negligently to cause or permit the life of such child to be endangered or the health of such child to be injured, or willfully or negligently to cause or permit such child to be placed in a situation that its life, health or morals may be endangered, or to cause or permit such child to be overworked, tortured, tormented, mutilated, beaten or cruelly treated.

Intent Level Willfully Class Negligently 6 felony

Available at, https://law.lis.virginia.gov/vacode/title40.1/chapter5/section40.1-103/

Sentence One to 5 years in prison

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Washington State code Wash. Rev. Code 9A.36.120 Childa abuse in the first degree

a

Relevant language (1) A person 18 years of age or older is guilty of the crime of assault of a child in the first degree if the child is under the age of thirteen and the person: (a) Commits the crime of assault in the first degree, as defined in RCW 9A.36.011, against the child; or(b) Intentionally assaults the child and either: (i) Recklessly inflicts great bodily harm; or(ii) Causes substantial bodily harm, and the person has previously engaged in a pattern or practice either of (A) assaulting the child which has resulted in bodily harm that is greater than transient physical pain or minor temporary marks, or (B) causing the child physical pain or agony that is equivalent to that produced by torture.

Intent Intentionally, recklessly

Level Class A

Sentence Up to life in prison

Available at, http://app.leg.wa.gov/RCW/default.aspx?cite¼9A.36.120

West Virginia N/A (W. Va. Code, § 61-8D-3 (2014). Child abuse resulting in injury (limited to parent or guardian) ((closest available statute according to Physical Child Abuse Penalties, NAT’L DIST. ATTORNEYS ASS’N (2014)))

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Wisconsin State code Wis. Stat. Ann. § 948.03a Physical abuse of a child

a

Relevant language (2) Intentional Causation Of Bodily Harm. (A) Whoever Intentionally Causes Great Bodily Harmb To A Child Is Guilty Of A Class C Felony. (B) Whoever Intentionally Causes Bodily Harmc To A Child Is Guilty Of A Class H Felony. (C) Whoever Intentionally Causes Bodily Harm To A Child By Conduct Which Creates A High Probability Of Great Bodily Harm Is Guilty Of A Class F Felony. (3) Reckless Causation Of Bodily Harm. (A) Whoever Recklessly Causes Great Bodily Harm To A Child Is Guilty Of A Class E Felony. (B) Whoever Recklessly Causes Bodily Harm To A Child Is Guilty Of A Class I Felony. (C) Whoever Recklessly Causes Bodily Harm To A Child By Conduct Which Creates A High Probability Of Great Bodily Harm Is Guilty Of A Class H Felony.

Intent ENGAGING IN REPEATED ACTS OF PHYSICAL ABUSE OF THE SAME CHILD. (a) Whoever commits 3 or more violations under sub. (2), (3), or (4) within a specified period involving the same child is guilty of the following: A Class A felony if at least one violation caused the death of the child. A Class B felony if at least 2 violations were violations of sub. (2) (a). A Class C felony if at least one violation resulted in great bodily harm to the child. A Class D felony if at least one violation created a high probability of great bodily harm to the child. A Class E felony.

Level Class A Class B Class C Class D Class E

Sentence Up to Life Imprisonment in prison Up to 60 years in prison Up to 40 years in prison Up to 25 Years in prison Up to 15 Years in prison

Available at, https://docs.legis.wisconsin.gov/statutes/statutes/948/03 Bodily Harm” Means Physical Pain or Injury, Illness, Or Any Impairment Of Physical Condition c “Great bodily harm” means bodily injury which creates a substantial risk of death, or which causes serious permanent disfigurement, or which causes a permanent or protracted loss or impairment of the function of any bodily member or organ or other serious bodily injury b

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Wyoming State code WY Stat 6–2503a Child abuse; penalty

Relevant language (b) A person is guilty of child abuse, if a person responsible for a child’s welfare, intentionally or recklessly inflicts upon a child under the age of eighteen (18) years: (i) Physical injuryb, excluding reasonable corporal punishment; (ii) Mental injuryc; or (iii) Torture or cruel confinement. (c) Aggravated child abuse is a felony punishable by imprisonment for not more than twenty-five (25) years if in the course of committing the crime of child abuse, as defined in subsection (a) or (b) of this section, the person intentionally or recklessly inflicts serious bodily injury upon the victim or the person intentionally inflicts substantial mental or emotional injury upon the victim by the torture or cruel confinement of the victim

Intent Intentionally, recklessly

Sentence Imprisonment for not more than 10 years, or 25 years if aggravated

a

Available at, https://law.justia.com/codes/wyoming/2016/title-6/chapter-2/article-5/section-6-2503 b (B) “Physical injury” means any harm to a child including but not limited to disfigurement, impairment of any bodily organ, skin bruising if greater in magnitude than minor bruising associated with reasonable corporal punishment, bleeding, burns, fracture of any bone, subdural hematoma or substantial malnutrition c A) “Mental injury” means an injury to the psychological capacity or emotional stability of a child as evidenced by an observable or substantial impairment in his ability to function within a normal range of performance and behavior with due regard to his culture

References Allasio, D., & Fischer, H. (1998). Torture v. clinical child abuse: What’s the difference. J. Clinical Pediatrics, 37, 267. Bottoms, B. L., et al. (2004). Religion related child physical abuse: Characteristics and psychological outcomes. Journal of Aggression, Maltreatment & Trauma, 8, 87. Finkelhor, D., Omrod, R. K., & Turner, H. A. (2007). Poly-victimization: A neglected component in child victimization. Journal of Child Abuse & Neglect, 31, 7. Knox, B. L., et al. (2014a). Child torture as a form of child abuse. Journal of Child and Adolescent Trauma, 38, 46–49. Knox, B. L., et al. (2014b). Child torture as a form of child abuse. Journal of Child and Adolescent Trauma, 37, 47.

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Knox, B. L., et al. (2014c). Child torture as a form of child abuse. Journal of Child and Adolescent Trauma, 37, 46. Lindberg, D. M., et al. (2015). Testing for abuse in children with sentinel injuries. The Journal of Pediatrics, 5, 135. Putnam-Hornstien, E. (2011). Report of maltreatment as a risk factor for injury death: A prospective birth cohort study. Child Maltreatment, 164, 164. Turner, H. A., Finkelhor, D., & Omrod, R. (2010). Poly-victimization in a national sample of children and youth. American Journal of Preventive Medicine, 38(3), 323. Vieth, V. (2014). From sicks to flowers: Guidelines for child protection professionals working with parents using scripture to justify corporal punishment. Mitchell Hamline L. Review, 40, 907.

Fractures

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Contents Fractures: An Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General Bone Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vitamin D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Parathyroid Hormone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Calcitonin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Phosphate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fracture Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fracture Morphology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fracture Biomechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Plastic Deformation and Greenstick Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Transverse Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Spiral Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Oblique Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Buckle Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Classic Metaphyseal Lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fractures and Specificity for Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Classic Metaphyseal Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rib Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scapular Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sternal Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Spinous Process Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Differential Diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. E. Wade (*) · S. Messner Stephanie V. Blank Center for Safe and Healthy Children, Children’s Healthcare of Atlanta, Child Abuse Pediatrics, Emory University, Atlanta, GA, USA e-mail: [email protected]; [email protected] E. Richer Children’s Healthcare of Atlanta, Pediatric Radiology, Emory University, Atlanta, GA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_248

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Osteogenesis Imperfecta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vitamin D Deficient Rickets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hyperparathyroidism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Menkes Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scurvy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Caffey Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Iatrogenic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Novel Theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “Temporary Brittle Bone Disease” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “Healing Rickets” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “Temporary Brittle Bone Disease” from In Utero Confinement . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ehlers-Danlos Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Obtaining History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Laboratory Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sibling Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Child abuse was the fourth leading cause of death among children 1–4 years of age in 2016 (Heron 2018), and fractures are the second most common type of physical injury due to child abuse (Flaherty et al. 2014). It is imperative that all healthcare professionals possess a good understanding of fractures that are more likely to be abusive in nature. In order to do so, one must have a solid knowledge of the basics of bone structure and health. This chapter provides a fundamental foundation for bone physiology and fracture pathology. It will discuss various fractures and their specificity for abuse. It will explore the mechanical forces necessary to create different types of fractures, equipping the reader with knowledge required to analyze history plausibility as it relates to the fracture in question. This chapter also examines syndromes, metabolic disorders, and diseases that can affect bone health and lead to fractures that could be mistaken for non-accidental trauma. It is also important to evaluate theories of fracture causation that healthcare providers may encounter in the literature or from other healthcare providers. This chapter will explore the medical evaluation needed when a child presents with an injury suspicious for abuse, including the requisite history, physical exam, laboratory studies, and radiologic imaging. Finally, this chapter will guide the healthcare provider through the child abuse evaluation, including the importance of having a pediatric radiologist involved, follow-up skeletal surveys, and the necessity of communication between the general pediatrician, the child abuse pediatrician, and the pediatric radiologist.

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Keywords

Fracture · Bone · Pediatric · Spiral · Buckle · Rib · Oblique · Transverse · Rickets · Metabolic

Fractures: An Introduction Fractures are a common childhood injury that can be traumatic or pathologic in nature. Traumatic fractures are due to either accidental or non-accidental forces. Evaluating fractures in a vulnerable group of patients such as the pediatric population involves more than simply diagnosing and treating the injury. A proper evaluation of pediatric fractures must include a complete assessment for possible nonaccidental trauma. Misdiagnosing the cause of a fracture can be detrimental to the patient and family. A misdiagnosed abusive fracture places the child at serious risk for further injury or even death, and a misdiagnosed accidental or pathologic fracture can have serious consequences for the caregivers of the child and prolong proper diagnosis of the causative pathology (Ravichandiran et al. 2010). Fractures are the second most common type of physical injury due to child abuse, bruises being the first (Flaherty et al. 2014). According to the National Child Abuse and Neglect Data System (NCANDS), there were approximately 674,000 child victims of abuse and neglect in 2017 (NCANDS 2017). 18.3% of those children, approximately 121,320 children, had documented injuries that were consistent with non-accidental trauma (NCANDS 2017). The exact number of children who have been physically abused is unknown since numerous cases of non-accidental trauma remain unreported. More than one quarter (28.5%) of the documented cases of child abuse in 2017 occurred in children less than 3 years of age with the highest percentile occurring in children less than 1 year of age (NCANDS 2017). An estimated 12% of fractures in children younger than 3 years of age are due to non-accidental trauma (Leventhal et al. 2008). Although children can suffer abusive injuries at any age, younger children are at a much greater risk for physical abuse. There is a strong inverse relationship between the age of the child and the likelihood that the injury was secondary to non-accidental trauma (Kemp et al. 2008). These statistics are supported by numerous evidence-based studies. Loder et al. evaluated 1794 cases of musculoskeletal injuries due to non-accidental trauma in hospitalized children throughout the country (Loder and Feinberg 2007). 59% of these musculoskeletal injuries were fractures. 49% of these injuries were found in children less than 1 year of age. The most common locations for abusive fracture were the skull and facial bones (27%), followed by femur (18%), ribs/sternum (17%), and humerus (11%). A small portion of these abusive injuries were fatal (3.5%), and most of the fatalities (90%) occurred in infants and toddlers. Accurately diagnosing non-accidental trauma is of paramount importance in ensuring a child receives the appropriate care. Ravichandiran et al. found that 20% of abusive fractures in children under the age of 3 years were misdiagnosed as accidental and 17% of these children subsequently presented to a healthcare provider

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with new abusive injuries (Ravichandiran et al. 2010). Two-thirds of the children returning for care were found to have healing fractures on radiograph, and the median delay in receiving an accurate diagnosis of abusive trauma was 8 days. It is therefore of utmost importance that healthcare providers understand how to evaluate the pediatric patient for non-accidental trauma correctly. Misdiagnosing child abuse as accidental trauma places the child at risk for continued abuse and even death.

General Bone Physiology Bone consists of an organic matrix and calcium salts. The organic matrix makes up approximately 30% of the bone, and 70% of the bone is comprised of salts, mostly calcium and phosphate. The majority of the organic matrix is made of collagen fibers, which extend along the lines of tensile force, providing tensile strength to the bone. The remainder of the organic matrix is comprised of ground substance, a combination of extracellular fluid and proteoglycans such as chondroitin sulfate and hyaluronic acid. The calcium salts provide the compressional strength of bone (Guyton and Hall 2006). Bone acts as a reservoir for calcium in the body, a buffer that maintains the necessary extracellular calcium concentration in the setting of deficiency or excess. Only about half of the circulating calcium is found in the ionized, biologically active form. The other 50% of circulating calcium is bound to proteins, mainly albumin (Jenny 2011). The continual process by which calcium is absorbed or excreted by the bone is controlled by osteoblasts and osteoclasts. This constant remodeling of bone not only helps maintain the appropriate extracellular calcium concentrations but also helps bone retain its strength as it ages and as it adapts to any stress placed upon it by mechanical forces. As the stress is increased over time, so is the deposition of bone, producing a thicker, stronger bone capable of bearing the increased compressional load. Depending on the stress that is placed upon the bone, the process of remodeling can even change the shape of the bone, optimizing its loadbearing capabilities or repairing an ill-set fracture. As a person ages, this remodeling process slows, leading to more brittle bones in old age. Children, however, have very rapid and efficient rates of absorption and deposition in the absence of any disease process or deficiency, providing great bone strength (Guyton and Hall 2006). Ossification (bone formation) is controlled by osteoblasts. Osteoblasts secrete collagen molecules and ground substance. The collagen molecules polymerize to form collagen fibers, which comprise the osteoid, a cartilage-like material. Calcium salts precipitate onto the surface of these collagen fibers and are converted into hydroxyapatite crystals, which mineralizes the matrix, forming new bone. Bone resorption is controlled by osteoclasts, phagocytic cells formed in the bone marrow. Osteoclasts release proteolytic enzymes, which break down the bone matrix as well as several acids which dissolve the salts (Guyton and Hall 2006).

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Adequate levels of extracellular calcium are necessary to maintain appropriate bone health. Serum calcium levels are regulated by parathyroid hormone (PTH) and activated vitamin D (1,25-dihydroxycholecalciferol). Deficiency or disruption of these two pathways can result in bone pathology, increasing an individual’s risk of fracture. A clear understanding of calcium homeostasis is necessary when evaluating the many differential diagnoses that must be considered when assessing a fracture for possible non-accidental trauma.

Vitamin D Vitamin D levels are maintained through appropriate dietary intake and exposure to the sun. A sterol found in the skin, 7-dehydrocholesterol, is irradiated by UV rays from sunlight, producing vitamin D3, also called cholecalciferol. Cholecalciferol is converted to 25-hydroxycholecalciferol in the liver. This conversion is controlled by an inhibitory feedback loop, which not only regulates the appropriate serum levels of 25-hydroxycholecalciferol but also preserves the stores of cholecalciferol in the liver. Cholecalciferol can be stored in the liver for several months, but once converted to 25-hydroxycholecalciferol, it is only available for several weeks (Guyton and Hall 2006) (Fig. 1). The production of cholecalciferol in the skin is affected by many different factors, which can predispose certain individuals to vitamin D deficiency. Melanin absorbs UV-B photons, decreasing the photoisomerization required to produce cholecalciferol in people with darker skin tones. Geographical location can also be a factor in vitamin D production, affecting an individual’s exposure to the sun through latitude and changes in weather. Other factors that affect the production of vitamin D are sunscreen use, pollution, and even the age of the patient. Breastfed infants under the age of 3 months are at a low risk of vitamin D deficiency if their mother has adequate vitamin D stores, because vitamin D metabolites cross the placenta. This allows infants to store enough vitamin D to last for the first 3 months of life. After 3 months of life, breastfed infants require vitamin D supplementation because breast milk does not provide the appropriate amount of vitamin D (Jenny 2011). 25-Hydroxycholecalciferol is then converted to the activated form of vitamin D, 1,25-dihydroxycholecalciferol, through a parathyroid hormone (PTH)-dependent reaction in the proximal tubules of the kidneys. This conversion is directly affected by serum calcium concentrations, as elevations in calcium have a slightly inhibitory effect on the conversion by decreasing circulating levels of PTH. Healthy kidneys and healthy parathyroid glands are, therefore, required for the appropriate synthesis of 1,25-dihydroxycholecalciferol (Guyton and Hall 2006). 1,25-Dihydroxycholecalciferol regulates calcium homeostasis through its actions on the intestines, kidneys, and bones. It increases absorption of calcium and phosphate by the intestines and also decreases renal excretion of calcium and phosphate into the urine, thereby increasing their absorption. It also promotes calcification in the bones (Costanzo 2006).

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Fig. 1 Vitamin D metabolism

Parathyroid Hormone Parathyroid hormone (PTH) is produced by the chief cells of the parathyroid gland. PTH increases formation of 1,25-dihydroxycholecalciferol in the kidneys, which increases the intestinal absorption of calcium and phosphate. PTH also increases the

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tubular reabsorption of calcium in the kidneys and decreases the reabsorption of phosphate. Phosphate can bind to calcium, making it unavailable for use in the ionized form. By decreasing the serum concentration of phosphate through increased urinary excretion, PTH is increasing the amount of available ionized calcium in the serum. PTH has two effects on the bone. Initially PTH increases osteoblastic activity, increasing bone deposition. This stimulation of the osteoblasts causes them to release cytokines that stimulate osteoclasts. In this way, PTH indirectly increases the osteoclastic activity, increasing bone resorption and increasing serum levels of calcium. PTH controls the calcium reservoir of the bone and, in healthy bone, could release enough calcium to maintain appropriate calcium homeostasis for at least 1 year, before depleting the bone of its calcium stores (Guyton and Hall 2006). Secretion of parathyroid hormone is influenced by several factors. Serum levels of calcium and magnesium regulate the production and secretion of PTH. Magnesium is required for the release of PTH from the parathyroid hormone. Magnesium also improves the end-organ response to PTH (Costanzo 2006). Calcium homeostasis is regulated directly and indirectly by several other factors. Serum levels of calcium and magnesium regulate the production and secretion of PTH. Hypomagnesemia will increase PTH secretion. Hypocalcemia will also increase PTH secretion, whereas hypercalcemia will inhibit PTH secretion via an inhibitory feedback loop. Dietary intake of sodium, protein, and fiber can affect calcium metabolism. Increased amounts of dietary sodium and protein can increase urinary calcium excretion, decreasing serum levels of calcium. High levels of dietary fiber can decrease intestinal absorption of calcium, which is why calcium in milk is much more biologically available than the calcium found in vegetables (Costanzo 2006; Jenny 2011).

Calcitonin Another hormonal regulator of calcium is calcitonin. Calcitonin is a peptide hormone made by the parafollicular cells (C cells) of the thyroid gland. It works to decrease serum calcium levels, but its effect is much weaker than that of PTH. Calcitonin decreases osteoclastic bone absorption, increasing deposition of calcium in new bone formation. Calcitonin also decreases the resorption of calcium by the kidney, increasing calcium excretion in the urine (Costanzo 2006; Guyton and Hall 2006).

Phosphate Phosphate is an important factor in bone health. 80–90% of phosphate is stored in hydroxyapatite, and phosphate homeostasis is regulated by renal resorption of phosphate, which is controlled by PTH. Phosphate is obtained through dietary

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sources such as fish, cheese, eggs, meat, bread, vegetables, and fruit. Aluminum and magnesium, however, will bind phosphate so that it is no longer biologically active. Therefore, chronic use of antacids that contain aluminum or magnesium can lower phosphate levels and lead to osteomalacia. Vitamin D also influences phosphate homeostasis by increasing intestinal absorption of dietary phosphate. Vitamin D deficiency will decrease intestinal absorption of phosphate along with decreasing serum ionized calcium levels, which in turn will increase PTH secretion, resulting in increased urinary excretion of phosphate by the kidneys (Jenny 2011).

Fracture Healing Bone healing occurs in three phases. The first phase, the inflammatory phase, takes place over hours to days after the initial injury. Injury to the bone and surrounding vasculature forms a hematoma and activates cytokines, growth factors, and prostaglandins, factors necessary for the healing process. Fibrovascular cells infiltrate the hematoma, forming a primary callus. During the second phase, the reparative phase, osteoblasts are recruited to the site of injury along with bone stem cells (osteoprogenitor cells), which increase the production of osteoblasts. This increase in number and activity of osteoblasts increases bone formation at the site of injury, resulting in subperiosteal new bone formation, which creates a soft callus. The soft callus is then ossified to form a hard callus. The reparative stage occurs over the span of several weeks (Kliegman et al. 2016; Wilkins 2005). During the final stage of healing, the remodeling phase, the osteoblasts respond to stress placed upon the bone. This allows a fractured bone to remodel as it heals. If a fractured bone starts to heal at an angle, the compression forces exerted on the bone will be increased on the inner angle and decreased on the outer angle of the fracture. The increased stress applied to the inner angle increases the deposition of new bone, while the decreased stress applied to the outer angle decreases the deposition of new bone. This highly controlled rate of remodeling which occurs at the inner and outer angles of the fracture should allow the bone to straighten as it heals (Guyton and Hall 2006). There are important factors that will affect the remodeling process: the age of the bone, distance of the fracture to the joint, and degree of injury. Younger children have more growth potential, which, in the absence of additional bone pathology, increases the efficiency of the remodeling process. Fractures located closer to a physis (growth plate), fractures located in the same plane as a joint, and fractures that require less repair will experience optimal remodeling. The remodeling phase continues for months and even years before the healing process is complete (Wilkins 2005). The process of fracture healing is also affected by which bone is fractured, the segment of the bone that is fractured, and the type of fracture that is sustained. Further discussion of these differences will be explored later in the chapter.

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Fracture Morphology The pediatric skeleton has various anatomic, physiologic, and biomechanical differences when compared to the adult skeleton, which can influence fracture patterns and the resultant healing process. Pediatric bones are less dense than adult bones due to decreased mineralization, and they are more porous than adult bones due to an increase in the number of Haversian canals and blood vessels. Pediatric bones also have more fibrous components, which, along with the decreased density, increase the elasticity and compliance of the bones. Due to the increased elasticity and compliance, pediatric bones are capable of absorbing more energy without injury than adult bones. The pediatric skeleton contains physes (growth plates), and the pediatric periosteum has greater osteogenic activity than adult periosteum. These characteristics, which are specific to pediatric bones, can result in fracture morphologies that are only found in the pediatric population (Kliegman et al. 2016; Pierce et al. 2004). The morphology of a fracture, a set of characteristics describing the fracture, is made up of several different components: the location of the fracture (which bone), the segment of the bone that is fractured (diaphysis, metaphysis, epiphysis), the type of fracture (spiral, buckle, transverse), any additional characteristics of the fracture (displaced, comminuted, separated, open), and any evidence of healing (periosteal reaction, callus formation). Fracture morphologies are dependent upon not only the age and bone development of the child but also the inherent properties and characteristics of each specific bone. There are multiple types of fractures, including spiral fractures, oblique fractures, transverse fractures, buckle (torus) fractures, classic metaphyseal lesions, and greenstick fractures (Fig. 2). A transverse fracture is perpendicular to the long axis of the bone. Transverse fractures occur along the diaphysis of a long bone, which consists of hard, compact bone (Fig. 3). A greenstick fracture is an incomplete transverse fracture of the shaft of a long bone. It is the increased elasticity and compliance of pediatric bones that is responsible for the greenstick fracture, a fracture that is only seen in young children (Fig. 4). Spiral fractures are fractures that take a spiral or helical course and tend to occur in long bones, such as the femur, tibia, fibula, radius, ulna, and humerus (Fig. 5). An oblique fracture is a combination of transverse and spiral fractures (Fig. 6). Buckle fractures and torus fractures are disruptions in the cortex of a long bone usually located at a distal metaphysis. The metaphysis of a long bone has a thin, porous cortex, which is more easily deformed by a compressive force (Fig. 7). A classic metaphyseal lesion (CML) is a planar microfracture of the metaphysis of a long bone. CMLs are often called “bucket handle fractures” or “corner fractures” due to their appearance on radiograph, which depends on the angulation of the x-ray beam relative to the long axis of the bone. As a fracture heals, the original fracture morphology disappears, and the presence of a periosteal reaction may be the only indication of the initial fracture (Fig. 8).

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Fig. 2 A transverse fracture of the femoral diaphysis

Different fracture morphologies have different specificities for abuse (Kleinman and Walters 2015). This will be discussed later in the chapter. Understanding the risk of abuse associated with different fracture morphologies can help guide a clinician’s evaluation of the fracture and influence the concern for non-accidental trauma.

Fracture Biomechanics When properly evaluating a fracture, healthcare providers must have a thorough understanding of the biomechanics required to create the injury. Kinetic energy can be applied directly or indirectly to a bone through a force, an action that moves or deforms an object such as a bone. When this force induces stress within the bone that surpasses the inherent strength of the bone, a fracture results. Several types of forces can act upon a bone, including tensile forces, compressive forces, and shear forces. When an individual force or combined forces are exerted onto an object, they create a load. Tensile forces and compressive forces

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Fig. 3 A greenstick fracture of the femoral diaphysis

each create axial loads but act in opposite manners. Tensile forces stretch the body part along the axis, and compressive forces squeeze the body part along the axis. Shear forces are unaligned forces that move the body part in opposite directions. Bones are anisotropic, meaning their properties are directionally dependent. The inherent strength of a bone depends upon its location within the body and the direction in which a force is applied (Bertocci et al. 2017; Pierce et al. 2004).

Plastic Deformation and Greenstick Fractures Plastic deformation and greenstick fractures are two types of fractures that are unique to children and result from the increased compliance, elasticity, and energy absorption of pediatric bones (Kliegman et al. 2016; Pierce et al. 2004). Plastic deformation occurs when a loading force is applied to the bone, causing permanent deformation without fracture. Several fracture types are grouped under the term plastic fracture, including greenstick, buckle, and torus fractures. Greenstick fractures develop as an incomplete crack through the bone when a

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Fig. 4 A spiral fracture of the femoral diaphysis

loading force is applied. The child’s developmental capabilities, the plausibility of the history provided, and any other findings concerning for non-accidental trauma should guide the clinician’s concern for abuse. Buckle fractures result from compressive forces applied to a child’s bone (Kliegman et al. 2016). Buckle fractures are common and are seen in patients throughout childhood due to the relative immaturity and flexibility of their bones compared to those in adults. When the bone is compressed at both ends, it can cause the bone to buckle or “crumple” under the force, commonly deforming one side of the bony cortex. A torus fracture is a type of buckle fracture in which the bone is deformed circumferentially at the fracture site, resembling a donut. Buckle fractures are

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Fig. 5 An oblique fracture of the femoral diaphysis

the result of lower-energy loading forces, resulting from almost ten times less the amount of energy required to create a transverse or short oblique fracture (Pierce et al. 2005). Buckle fractures are considered stable fractures, meaning the bone is not broken into pieces that separate from each other (Pierce et al. 2004). Buckle fractures are often seen as a result of a fall. For example, a toddler who is learning to run and falls onto an outstretched arm may present with a buckle fracture of the distal radius. Buckle fractures can also be seen after an infant is dropped onto the ground and lands on an outstretched arm or leg. Abusive trauma must remain high on the differential in children who are not developmentally capable of causing such an injury or verbalizing the history of the fracture. Understanding the developmental capabilities of the child is again of utmost importance in order to evaluate the plausibility of the history provided. If a child is not able to communicate with a clinician to confirm the history provided about the cause of the injury, non-accidental trauma must remain on the differential even if the history provided could account for the injury in question (Figs. 9 and 10).

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Fig. 6 A buckle fracture of the femoral diaphysis

Transverse Fracture A transverse fracture occurs as the result of a bending load applied to a long bone either directly or indirectly (Bertocci et al. 2017). Blunt force trauma to the diaphysis of a long bone results in a direct force that is applied to the bone. This force induces opposing tensile and compressive stress within different areas of the bone, which results in a transverse fracture (Pierce et al. 2004). Transverse fractures can also result from an indirect application of bending and compressive loads, which can be seen when a child falls down the stairs, landing on a knee, resulting in a transverse fracture of the femur. A transverse fracture requires almost ten times the amount of loading force required to create a buckle or spiral fracture (Pierce et al. 2005). Transverse fractures result from high-energy trauma. Pierce et al. evaluated fractures sustained from stair falls, and no transverse fractures resulted from an indirect, lowenergy, simple stair fall (Pierce et al. 2005). A high-energy mechanism was required such as the additional momentum of a co-fall, the direct impact of the caregiver landing on the child, or, in one case whose initial history proved to be false, the child was reportedly thrown against a wall. Transverse fractures are commonly seen in both accidental and non-accidental trauma. The child’s developmental capabilities,

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Fig. 7 Classic metaphyseal lesions of the distal femur, illustrating both the “corner” and “bucket handle” appearances

the plausibility of the history provided, and any other findings concerning for nonaccidental trauma should guide the clinician’s concern for abuse. As with greenstick fractures, the clinical picture and history should guide a clinician’s concern for nonaccidental trauma (Fig. 11).

Spiral Fracture The architecture of pediatric long bones makes them stronger when placed under axial loading forces than when placed under torsional loading forces (Bertocci et al. 2017). Osteoblasts lay down the bone in a linear fashion along the long axis of the bone, providing a great resistance to axial loading forces but a lower injury threshold when placed under a torsional (or rotational) load. When a long bone is fixed at one end and a torsional load is applied, shear forces are created between the transverse parallel planes of the bone. The shearing forces, in combination with compressive and tensile loads exerted throughout the bone, induce a spiral fracture in the absence of an associated high-impact or high-energy mechanism (Bertocci et al. 2017; Pierce et al. 2004). Spiral fractures are the result of lower-energy loading forces, resulting from almost ten times less the amount of energy required to create a transverse or short oblique fracture (Pierce et al. 2005).

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Fig. 8 Periosteal reaction of the diaphysis and metadiaphysis of the femur

Spiral fractures are frequently seen in the lower extremities of toddlers who are learning to walk; thus, a spiral fracture of the tibia is often called a “toddler’s fracture,” a term that was first coined by Dunbar in 1964 (Gladstone 1964). Planting the foot and rotating the leg will induce the necessary loading forces needed to overcome the inherent strength of the long bone, resulting in a spiral fracture. Spiral fractures can also result from a simple stair fall, often reported as the affected leg having folded or twisted beneath the child as he or she fell (Pierce et al. 2005). Once thought to be pathognomonic for abuse, spiral fractures can have a low specificity for abuse if the child is developmentally capable of inducing the forces required to cause such a fracture or if there is a plausible, reported accidental history to account for the injury. However, spiral fractures can be abusive in nature as well. For example, a child’s leg which is fixed in place at one end by the child’s body can be forcefully rotated by a caregiver, inducing a spiral fracture. A spiral fracture in a lower limb of a child who is developmentally incapable of standing and walking, or a spiral fracture when combined with other concerning physical exam findings, should increase suspicion for an abusive injury (Figs. 12 and 13).

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Fig. 9 Forearm radiographs in two different patients demonstrate greenstick fractures of the radius (left) and radius and ulna (right). The fractures disrupt one side of the bone, leaving the opposite cortex intact

Oblique Fracture Similar to spiral fractures and transverse fractures, oblique fractures can result from a combination of a compressive axial load, bending load, torsional forces, or bending forces alone. The degree of torsion contributes to the length of the oblique fracture (Pierce et al. 2004). Short oblique fractures occur when a compressive load or bending load is the primary acting force, whereas long oblique fractures occur when torsion is the primary acting force. Research has demonstrated that short oblique fractures require up to ten times the loading force that is required to create a buckle or spiral fracture (Pierce et al. 2005). Pierce et al. evaluated fractures sustained from stair falls, and no short oblique fractures resulted from an indirect, low-energy, simple stair fall (Pierce et al. 2005). A high-energy mechanism was required such as the additional momentum of a co-fall or the direct impact of the caregiver landing on the child.

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Fig. 10 AP and lateral views of the wrist show cortical buckling and deformity of the distal radius without distinct fracture line (arrows) consistent with a buckle or torus fracture

Fig. 11 Femur radiographs in two different patients show transverse diaphyseal fractures, which extend essentially horizontally through the bone and disrupt both cortices

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Fig. 12 Femur (left) and humerus (right) radiographs in two different patients demonstrate spiral fractures. Note the helical course the fractures take through the bones, distinguishing them from simple oblique fractures

It can be difficult to differentiate between long oblique fractures and spiral fractures on radiographs; however, the biomechanics required for each fracture is different. Understanding these differences can be crucial to determining the level of concern for abuse based on the reported history. Oblique fractures can be accidental or abusive in nature. Again, the developmental capabilities of the child, the plausibility of any reported accidental history, and any other suspicious injuries can help guide a clinician’s concern for abusive vs. accidental trauma (Fig. 14).

Buckle Fracture Buckle fractures result from compressive forces applied to a child’s bone (Kliegman et al. 2016). Buckle fractures are sometimes referred to as torus fractures; however, torus fractures are a specific subtype of buckle fractures, a circumferential buckle fracture that creates a ring-like or donut-shaped deformity that encompasses the entire circumference of the bone. Buckle fractures are common and are seen in

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Fig. 13 Tibia and fibula radiographs in three different patients show the typical appearance of toddler fractures. The fractures are commonly very subtle, hairline, oblique fractures of the mid to distal tibia

patients throughout childhood due to the relative immaturity and flexibility of their bones compared to the bones of adults. When the bone is compressed at both ends, it can cause the bone to buckle or “crumple” under the force. Buckle fractures are the result of lower-energy loading forces, resulting from almost ten times less the amount of energy required to create a transverse or short oblique fracture (Pierce et al. 2005). Buckle fractures are considered stable fractures, meaning the bone is not broken into pieces that separate from each other (Pierce et al. 2004). Buckle fractures are often seen as a result of a fall. For example, a toddler who is learning to run and falls onto an outstretched arm may present with a buckle fracture of the distal radius. Buckle fractures can also be seen after an infant is dropped onto the ground and lands on an outstretched arm or leg. Abusive trauma must remain high on the differential in children who are not developmentally capable of causing such an injury or verbalizing the history of the fracture. Understanding the developmental capabilities of the child is again of utmost importance in order to evaluate the plausibility of the history provided. If a child is not able to communicate with a clinician to confirm the history provided about the cause of the injury, non-accidental trauma must remain on the differential even if the history provided could account for the injury in question.

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Fig. 14 Femur radiograph shows a typical oblique diaphyseal fracture. The fracture line is not horizontal as in a transverse fracture, but also does not take a helical course, as in a spiral fracture

Classic Metaphyseal Lesion Classic metaphyseal lesions (CMLs) are also called “corner fractures” or “bucket handle fractures.” These fractures are most commonly seen in young infants who are not capable of creating the forces necessary to cause such fractures. The exact biomechanics responsible for CMLs are not well understood. It has been proposed that these fractures occur when a shearing or tensile force has been placed upon a long bone, creating a planar fracture through the immature bone of the metaphysis (Pierce et al. 2004). These forces are theorized to occur in several scenarios: the violent pulling or twisting of an extremity or the violent shaking of a child, inducing acceleration-deceleration forces on the joints of the extremities (Thompson et al. 2015). Several different experimental models have attempted to define the biomechanics responsible for CMLs. Tsai et al. evaluated the resultant cortical strain produced by forcefully applying eight different load scenarios to a geometric model of a 3-monthold infant’s distal tibia. Tension, compression, dorsiflexion, plantar flexion, valgus bending, and varus bending produced significant cortical strain; however, tensile forces produced the greatest cortical strain, suggesting that the tensile forces created by forcefully yanking or pulling an extremity could result in a CML (Tsia et al. 2017). Thompson et al. applied varus and valgus bending forces to 24 immature piglet pelvic limbs by using an electromechanical testing machine (Thompson et al. 2015). Half of the piglets developed fractures consistent with CMLs as a result, and most of the fractures occurred at the medial portion of the tibia or femur, which supports previous theories that anatomical differences in the medial and lateral

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Fig. 15 Radiographs in four different patients show classic metaphyseal lesions (CMLs) in various degrees of healing. Previously termed “corner” or “bucket handle” fractures, the fracture appearance can be variable depending on orientation on the radiograph and extent of the injury

aspects of the long bones predispose the posteromedial metaphyses to CMLs (Kleinman and Marks 1996, 1998). Adamsbaum evaluated perpetrator confessions in 27 cases of child abuse. The confessions were analyzed, and the actions reported to have caused CMLs (yank, pull, twist, and shake) were interpreted as torsion, traction, and compressive forces (Adamsbaum et al. 2019). Further research is needed to determine conclusively the exact biomechanics required to cause a CML (Fig. 15).

Fractures and Specificity for Abuse Certain fractures have different specificities for non-accidental trauma based on either the biomechanics required to cause the fracture or the protected anatomical location of the bone. Different types of fractures can be associated with high, moderate, or low specificities for abuse (Kleinman and Walters 2015). Fractures with a high specificity for abuse include classic metaphyseal lesions, rib fractures, scapular fractures, spinous process fractures, and sternal fractures. These fractures, when identified in the absence of a plausible accidental history, require a thorough evaluation for non-accidental trauma (Fig. 16).

Classic Metaphyseal Lesions Classic metaphyseal lesions (CMLs) are highly specific for abuse and are often seen in infants who are at high risk for abuse (Kleinman et al. 2011). Caffey first associated these fractures with abuse in 1972 when he found CMLs to be the most common fracture caused by parent-infant stress syndrome, a syndrome latter known as “battered baby” syndrome (Caffey 1972). Lindberg et al. found that CMLs were the fourth most common fracture (4.7%) identified in children who were evaluated due to a concern for non-accidental trauma, and Kleinman found that CMLs are the

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Fig. 16 Specificity of abuse for various fracture types in infancy

most common fracture in children who have died from abusive injuries (Kleinman et al. 1995; Lindberg et al. 2013). Kleinman et al. evaluated CMLs via radiographs and histological examination, determining that “a transmetaphyseal disruption of the trabeculae of the primary spongiosa occurs,” creating a fragmented disk consisting of cartilage and bone (Kleinman et al. 1986). Kleinman concluded that CMLs were not the result of an avulsion, tearing the periosteum away at its insertion site, but a result of a “planar shearing force or tension through the most immature portion of the metaphyseal trabeculae.” CMLs are the result of trauma (Kleinman 2008). The mechanism of action required to induce a CML is evident in documented traumatic, iatrogenic causes: birth trauma and club foot casting (Grayev et al. 2001; O’Connell and Donoghue 2007). These medical procedures may require pulling, yanking, and twisting of an arm or a leg during a difficult birth or during casting of a clubfoot and have been found to result in CMLs. As previously mentioned, the appearance of a CML on radiograph is classically described as a “bucket handle” or “corner fracture” due to their appearance, but there

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are multiple radiographic findings that are consistent with CMLs. The varying radiological findings can be attributed to the differences in the underlying health of the bone, extent of injury, differences between the nature of force applied to cause the injury, angle of the radiograph, age of the injury, degree of healing, and quality of the imaging. CMLs do not always have the same signs of healing that are seen when other segments of a long bone are fractured, namely, subperiosteal new bone formation or callus (Kleinman 2008). Although CMLs can demonstrate subperiosteal new bone formation during the healing process, they often do not. Instead the histologic changes, including osteoclastic and osteoblastic activity, lead to a gradual and often invisible resolution of the fracture. Nearly one-third of healing CMLs of the distal tibia fail to demonstrate obvious signs of healing on imaging even when anteroposterior, lateral, and follow-up images are obtained (Tsai et al. 2019). The use of AP images alone detects subperiosteal new bone formation in only 34% of distal tibial CMLS. These results are significantly increased (71%) when initial lateral views or follow-up images are added, emphasizing the importance of multiple views and repeat radiographs when evaluating CMLs. However, the lack of obvious signs of healing of a CML should not be used to determine the timing of the injury or negate the traumatic nature of the injury.

Rib Fractures Rib fractures, especially posterior rib fractures, are also highly specific for abuse (Flaherty et al. 2014; Kemp et al. 2008; Kleinman and Walters 2015). Rib fractures can occur in anterior ribs, lateral ribs, and posterior ribs. Rib fractures can occur by two different mechanisms: compression of the rib cage and blunt force trauma. In children, the most common cause of rib fractures is anterior-posterior compression of the thoracic cage (Kleinman and Walters 2015). This compression is often due to squeezing of the chest cavity by a caregiver’s hands. Research has demonstrated that although accidental injury, such as motor vehicle accidents, falls downstairs, and falls out of windows, can cause rib fractures, accidental trauma is rarely the cause of rib fractures in children, especially posterior rib fractures. Kemp et al. performed a meta-analysis of 7 cross-sectional studies evaluating rib fractures, which included a total of 233 children. The various studies attributed rib fractures to physical abuse, bone dysplasia, prematurity, motor vehicle collisions or violent trauma, surgical trauma, birth injuries, and unknown or other non-abusive traumatic causes. When reported rib fractures from accidental (motor vehicle collisions and other violent trauma) and iatrogenic causes (surgery) were excluded, the probability that a rib fracture was the result of inflicted trauma was 0.71 (95% confidence interval 0.42 to 0.91), demonstrating that rib fractures had the highest probability for inflicted trauma (Kemp et al. 2008). Abused children sustain a greater quantity of rib fractures than children who sustained accidental trauma, but the abusive rib fractures are less likely to be associated with intrathoracic injury. Rib fractures secondary to non-accidental

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Fig. 17 Chest radiographs in three different patients demonstrating rib fractures. Nearly healed posterior rib fractures are present in the left image. Fractures in earlier stages of healing are seen in the center and right images (white arrows). Additional acute posterior rib fractures were also present in the right image (black arrows). Oblique chest radiographs are extremely valuable in detection of subtle rib fractures

trauma are more often bilateral, associated with long bone fractures, and associated with retinal hemorrhages. Most abusive rib fractures are thought to be due to forcible squeezing of the thoracic cavity, whereas most accidental rib fractures are due to blunt force trauma from a fall or motor vehicle accident (Kemp et al. 2008). It is a common misconception that CPR (cardiopulmonary resuscitation) will frequently cause rib fractures. The incidence of rib fractures in adults secondary to CPR is increased; however, research has shown that this is not the case in children. Betz et al. reviewed autopsy reports of 233 children, 190 of whom died from nontraumatic events and 43 whose cause of death was related to trauma (Betz and Liebhardt 1994). Ninety-four of the non-traumatic causes of death were found to have undergone CPR, and only two children were found to have rib fractures. These rib fractures were anterior rib fractures in the midclavicular line. Franke et al. evaluated 50 infants who underwent “two-thumbs” CPR after birth, which requires the healthcare provider to encircle the thoracic cage with their hands and press the sternum with their thumbs (Franke et al. 2014). No rib fractures were found on radiographic evaluation. Rib fractures, especially posterior rib fractures, are highly specific for non-accidental trauma. However, anterior rib fractures are very rarely caused by chest compressions during resuscitation efforts (Fig. 17).

Scapular Fractures Scapular fractures are very rare, and very little research about scapular fractures in children is available. Most of the information available about scapular fractures is from research on adult patients. The scapula is a relatively protected area of the body, a flat, mobile bone surrounded by protective musculature and connective tissue (Ropp and Davis 2015). Injury to the scapula is usually the product of a high-energy trauma such as direct blunt force (Cole et al. 2013). Due to the high-energy nature

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Fig. 18 Radiographs in three different patients show an acute scapular body fracture (left) and healing acromial process fractures (center, right). The patient in the right panel also had a humeral CML (black arrow)

required to induce scapula fractures, there are often other serious concomitant injuries. Research has shown that 80–95% of patients with a scapular fracture have associated injuries and as many as 10–15% of these cases will prove to be fatal. The absence of a plausible, high-energy, accidental history to account for a scapular fracture should raise significant concern for inflicted injury. Baldwin et al. evaluated 9453 patients with scapula fractures compared to 2728 control patients without scapular fractures who were entered in the National Trauma Database (Baldwin et al. 2008). These patients were evaluated for additional injuries in the hope of identifying associated injuries which are more likely to occur in the presence of a scapula fracture. The most common injuries associated with scapular fractures were rib fractures, any lung injury, clavicle fractures, pneumothorax, and spinal fractures; these injuries occurred at a frequency 2–1/2 to 8 times higher among patients with scapular fracture, compared to controls. Many scapular fractures will go undetected initially due to the serious and often life-threatening nature of concomitant injuries. Adult patients with scapular fractures are often unconscious, and, much like very young pediatric patients, they are unable to participate in the gathering of medical history or physical exam. It is therefore very important to evaluate for scapular fractures whenever a patient has suffered extensive injury to the thoracic cage or thoracic cavity. Non-accidental trauma must remain high on the differential whenever a scapular fracture is identified in a child, particularly when there is no history of high-impact trauma (Fig. 18).

Sternal Fractures Sternal fractures are also very rare and, like scapular fractures, require a high-energy force such as a direct blow to the chest. Similar to scapular fractures, they are also usually associated with other concomitant injuries to the thoracic cavity and cage. Von Garrel et al. evaluated 200 pediatric and adult patients who had sustained sternal fractures over a 10-year period (Von Garrel et al. 2004). The most common cause (83%) of sternal fractures was found to be traffic accidents. 63% of the patients were found to have concomitant injuries, with rib fractures, chest injuries, and cardiac

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Fig. 19 Lateral chest radiographs in three different patients show a dislocated sternal segment (left), sternal buckle fracture (center), and depressed sternal fracture (right)

injuries being the most commonly found. Just as with scapula injuries, the suspicion for non-accidental trauma must remain high whenever a sternal fracture is identified in a child, especially if there is no history of high-energy trauma (Fig. 19).

Spinous Process Fractures Spinal fractures are not commonly found in children, accounting for an estimated 0.8% of child abuse cases (Pandya et al. 2009). Spinous process fractures, however, have a high specificity for abuse (Kleinman and Walters 2015). Anatomic and biomechanical differences between the bony spinal column of an infant and that of an adult contribute to the infrequency of spinal fractures found in the younger population. Portions of the pediatric spine, including spinal ligaments and cartilaginous structures, are more elastic in nature than those found in the adult spine, allowing for flexibility in the face of loading forces without inducing injury. The anatomy of the facet joints and the uncinate processes of the child’s spine allow more mobility than the adult spine is capable of having. The combination of these factors allows the child’s spine to undergo greater extension and flexion than an adult’s spine without inducing bony injury. A child’s head is also disproportionately large when compared to its body and the infant’s neck muscles are underdeveloped, which can put the child at increased risk for hyperextension and flexion injuries. By 8 years of age, the child’s spine starts to develop anatomic changes seen in an adult spine, causing a more stable spine that is more resistant to flexion and hyperextension injuries. By the age of 16–18, the child’s spine assumes adult anatomy. Spinous process fractures occur when the spinous process of the vertebrae is fractured usually at the location of the interspinous ligament attachment. Kleinman, who originally categorized the spinous process fracture as highly specific for abuse,

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theorized that the sudden acceleration-deceleration forces exerted on an infant during violent shaking or hyperflexion of the spine in an older child could result in avulsion of the spinous process (Kleinman and Zito 1984); however, fractures of the spine have not been well reported as the result of violent shaking. Barber et al. performed a retrospective study of 751 children with suspected abuse (Barber et al. 2013). Fourteen of these children had spinal fractures, but none were fractures of the spinous process. The incidence of spinous process fractures is low, and research on the injury and its association with abuse is scant. Kleinman and Zito performed a study reviewing the charts of 19 physically abused infants who were younger than 5 months of age (Kleinman and Zito 1984) Three of the infants (16%) had spinous process injury evident on imaging: two had findings consistent with surrounding soft tissue injury or cartilage avulsion, and one had findings consistent with an avulsion of the spinous process. Spinous process fracture can occur as the result of blunt force trauma to the spine. There is very limited literature regarding spinous process fractures as they relate to abuse. The magnitude of high-energy, blunt force trauma required to fracture the spinous process can be better understood by evaluating the accidental mechanisms of injury that are most commonly the cause of spinous process fractures such as motor vehicle collisions, motorcycle collisions, or ATV collisions (Akinpelu et al. 2016). Knox et al. performed a case review of 206 pediatric patients who presented to a large level I pediatric trauma center over 9 years with spinal injury (Knox et al. 2014a). The children were divided into two groups based on their age: the infantile group included children between 0 and 3 years of age, and the young group included children between the ages of 4 and 9 years. 2% of infants and 6% of young children with spinal injury were found to have a spinous process fracture. The mechanisms of injury accounting for the various spinal injuries included high-energy, blunt force trauma such as motor vehicle collision (most common), motor vehicle versus pedestrian collisions, ATV and motorcycle collisions, and non-accidental trauma. The majority of spinal fractures associated with child physical abuse are vertebral compression fractures (Barber et al. 2013). Compression fractures of the vertebrae occur when the spine is shortened by a force at either end such as occurs when slamming a child down by the shoulders forcefully in a seated position onto a firm surface. No matter the type of fracture, fractures of the spine are considered strong indicators of inflicted injury especially in children younger than 2 years of age (Kemp et al. 2010). There is also a strong association between spinal injury and abusive head trauma. Spinal fractures are rarely self-inflicted, and the suspicion for non-accidental trauma must remain high whenever a fracture of the spine is identified (Fig. 20). Fractures with a moderate specificity for abuse include multiple fractures (especially bilateral), fractures of different ages with various stages of healing, epiphyseal separations, vertebral body fractures and subluxations, digital fractures, and complex skull fractures (Kleinman and Walters 2015). These fractures can be seen as a result of accidental trauma, but are concerning for abusive injury until proven otherwise.

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Fig. 20 AP and lateral spine radiographs in an infant showed questionable subtle compression at several levels (left, center, arrows). Corresponding sagittal T2-weighted fat-suppressed magnetic resonance (MR) image (right) confirmed these as compression fractures; the MRI better demonstrated the extent of injury, with T2 hyperintense edema and compression fractures at nearly every thoracic level (arrows)

Fractures that are commonly seen and have a low specificity for abuse include subperiosteal new bone formation, clavicular fractures, long-bone shaft fractures (e.g., toddler’s fracture) in ambulatory patients, and linear skull fractures (Kleinman and Walters 2015). These fractures are commonly seen in children as the result of accidental trauma. A good understanding of the biomechanics required to produce specific types of fractures remains important when evaluating fractures with moderate and low specificity for abuse. Proper evaluation of the plausibility of the history provided, along with an evaluation of the child’s development and physical capabilities, will provide the clinician information about the possibility of abuse (Fig. 21).

Differential Diagnoses Not all fractures require high force trauma. Some fractures are a result of bone pathology and may be the result of minimal trauma. It is important to understand the various pathologies that can cause poor bone health and make a child’s bones more

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Fig. 21 Skull radiograph (left) and corresponding surface-rendered 3D computed tomography (CT) image (center) in one patient demonstrate a linear skull fracture of the right parietal bone. Skull radiograph in a different patient (right) demonstrates biparietal skull fractures which nearly overlap on this lateral view. The left parietal fracture is indicated by white arrows and the right by black arrows

susceptible to injury. There are multiple disease processes, deficiencies, and even iatrogenic causes of bone demineralization that can lead to weakened bones.

Osteogenesis Imperfecta Osteogenesis imperfecta (OI) is a genetic connective tissue disorder that can present in multiple forms, which affect bone health to varying degrees. The milder forms of the disease may cause only limited impairment, whereas the more severe forms can be lethal in utero. Numerous gene mutations have been associated with OI; however, the most common genes affected are the genes responsible for coding type I collagen, COL1A1 and COL1A2 (Kliegman et al. 2016). Type I collagen is the primary component of the bone’s extracellular matrix. It is a heterotrimer made of two alpha 1 chains and one alpha 2 chain that form a helix (Tournis and Dede 2018). Eighty percent of the mutations are point mutations, leading to substitutions in amino acids and disrupting the helical formation of the protein. Twenty percent of the mutations are single exon splicing mutations which lead to alterations in the protein production. Classical OI subtypes (OI Types I–V) are autosomal dominant. Recessive OI subtypes (OI VI–XI) are caused by null mutations (mutations which result in complete lack of gene product or a product which does not function properly) in various genes which code for different components of collagen (Kliegman et al. 2016). OI Type I is a milder form of the disease and is the most common form. Patients affected by OI Type I often have blue sclera and hearing loss. Bone fractures occur and are often seen with the initiation of ambulation. Other symptoms include hyperextensible joints, easy bruising, thin skin, scoliosis, and wormian bones (intrasutural bones of the skull). People who suffer from OI Type I can reach normal adult height or display only mild short stature. OI Type I does not involve dentinogenesis imperfecta (genetic disorder of tooth development from defective

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dentin which causes tooth discoloration) (Glorieux 2008; Kliegman et al. 2016; Rauch 2004). OI Type II is lethal in the perinatal period. Infants are either still born or die within the first year of life due to complications. These patients suffer from extreme bone fragility with multiple intrauterine manifestations, including a small thoracic cavity which can affect respiration, multiple fractures, bowing of the extremities and micromelia (small and abnormally shaped extremities), an enlarged skull, and enlarged anterior and posterior fontanelles. Patients will have dark blue or gray sclera. They can also suffer from defects of the cerebral cortex, leading to agyria, gliosis, and periventricular leukomalacia. If infants survive the birthing process, they often die from respiratory insufficiency (Glorieux 2008; Kliegman et al. 2016; Rauch 2004). OI Type III is the most severe non-lethal form of the disease. It is considered to be progressively deforming and greatly affects a patient’s quality of life. Infants with OI Type III suffer multiple intrauterine fractures. They are small with low birth weight and low birth length. They suffer from microcephaly and abnormal facies (triangular facies). They suffer postnatal fractures which often heal with residual bony deformities. These patients are usually wheelchair bound and experience respiratory compromise due to abnormalities of the thoracic cage. Patients with OI Type III often develop hearing loss, kyphosis, and dentinogenesis imperfecta (Glorieux 2008; Kliegman et al. 2016; Rauch 2004). OI Type IV is the most difficult to diagnose. It rarely presents with the more common signs of OI. The sclera of these patients is usually white, and their bone density can appear normal for the first few years of life. Patients may suffer from mild to moderate scoliosis and develop dentinogenesis imperfecta. The mutations that lead to OI Type IV are often spontaneous and, therefore, require no family history of the disease. The severity of OI Type IV is variable, leaving some patients wheelchair bound, while others ambulate easily with orthopedic intervention (Glorieux 2008; Kliegman et al. 2016; Rauch 2004). OI Type V is an autosomal dominant disease; however, the gene affected is not COL1A1 or COL1A2. OI Type V is due to a defect in IFITM5 (interferoninduced transmembrane protein 5), which is an osteoblast membrane protein necessary for proper bone mineralization in utero. This form of the disease does not present with blue sclera or dentinogenesis imperfecta. It often leads to a hyperplastic callus with associated warmth and swelling overlying the fracture. Another common sign of OI Type V is impaired movement of the wrist due to calcification of the interosseous membrane of the forearm (Glorieux 2008; Kliegman et al. 2016; Rauch 2004). OI Type VI is an autosomal recessive disorder, which leads to a mineralization defect only seen on bone biopsy. The histology of the bone reveals excess osteoid deposition and fish scale lamellation. Patients usually have white sclera and no dentinogenesis imperfecta. This disease leads to moderate to severe bone fragility. OI Type VII and Type VIII are due to autosomal recessive defects in CRTAP and LEPRE1, respectively. These genes are responsible for coding the proteins necessary for the proper hydroxylation of collagen. These two forms of OI range from severe to

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lethal, often resulting in rhizomelia, severe osteochondrodysplasia, and extreme short stature (Glorieux 2008; Kliegman et al. 2016; Rauch 2004). The ability to perform genetic testing to evaluate for mutations in the COL1A1 and COL1A2 genes has become more readily available through DNA-based sequencing on blood samples. Sometimes, a “variant of unknown significance” or a “novel” genetic mutation is detected, and the interpretation of these mutations are not well understood or have no clinical significance. Although there is ongoing work to formulate a more standardized approach to the interpretation of these cases, consultation with a medical geneticist should be sought in these circumstances (Canter et al. 2019) (Fig. 22).

Vitamin D Deficient Rickets Vitamin D deficient rickets can greatly affect bone health and strength. Vitamin D promotes bone health by increasing the absorption of calcium and phosphate by the intestine, increasing renal reabsorption of phosphate and calcium, and increasing bone calcification. Although the exact levels of Vitamin D required to induce rickets in children is not easily established, it is generally accepted that normal vitamin D levels, established by measuring the amount of 25-hydroxyvitamin D, are 30 ng/ml or greater. Vitamin D insufficiency is generally accepted as levels ranging between 20 and 30 ng/ml, and vitamin D deficiency is any level less than 20 ng/ml (Golden and Abrams 2014). Vitamin D deficient rickets is most often diagnosed in children between the ages of 3 months and 18 months (Wagner and Greer 2008).

Fig. 22 Chest radiograph shows irregular ribs bilaterally with mildly angulated fractures of several left ribs. Images of the femur (center) and tibia and fibula (right), however, also showed demineralized bones and osseous bowing, in keeping with the patient’s underlying diagnosis of osteogenesis imperfecta

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A deficient serum level of vitamin D, 25-hydroxyvitamin D, is not enough to establish the diagnosis of rickets or account for any fractures found on imaging. Vitamin D-deficient rickets can only be diagnosed based on the combination of clinical findings, radiologic evidence, and laboratory analysis (Misra et al. 2008). Specific radiologic findings of rickets are best seen at the sites of rapid growth where impairment of bone deposition will be most important, namely, at the growth plates of the long bones. Initial changes seen in rickets include widening of the epiphyseal plate and loss of the provisional zone of calcification. Widening, cupping, fraying, cortical spurs, and stippling can be seen as the disease progresses along with thinning of the bone cortex and generalized osteopenia. Frontal and parietal bossing, craniotabes (softening of the skull), rachitic rosary (enlargement of the ribs at the costochondral junction), Harrison grooves, and Looser’s zones are other skeletal changes that can be seen in advanced vitamin D-deficient rickets. Harrison’s grooves are depressions made in the softened lower ribs due to the traction caused by the diaphragm muscles. Looser’s zones, also known as Milkman’s pseudofractures, are often seen in osteomalacia, appearing as bilateral and symmetric pseudofractures or fissures within the bone (Figs. 23, 24, 25, 26, and 27). Laboratory findings in vitamin D-deficient rickets will depend upon the age of the child as well as the severity of the disease (Misra et al. 2008). Common laboratory findings will be a decreased serum level of vitamin D, elevated alkaline phosphatase, decreased phosphorous, and elevated parathyroid hormone (PTH). Calcium levels depend upon the severity of the disease, the remaining store of calcium, and the effects of PTH. Gordon et al. evaluated the prevalence of vitamin D deficiency in 380 infant and toddler outpatients in the Boston area and found that 12% met the laboratory definition of vitamin D deficiency (20 ng/mL) and only 7% met the laboratory definition of severe vitamin D deficiency (8 ng/mL) (Gordon et al. 2008). Forty (90%) of the vitamin D-deficient children underwent radiographic evaluation for evidence of rickets, and only 7.5% demonstrated rachitic bone changes. Although

Fig. 23 An 8-month-old infant presented with a distal femur fracture (left, arrow), but on complete skeletal survey was also noted to have demineralized bones and “cupping” and “fraying” of the distal radial and ulnar metaphyses (center, right), findings which are characteristic for rickets

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Fig. 24 Frontal and lateral views of the skull show findings of rickets, including an undermineralized calvarium, particularly at the skull base (white arrows), and a prominent anterior fontanelle (black arrows)

Fig. 25 Patient with rickets with Looser’s zones noted in multiple bones (arrows, a–c). Also note the typical metaphyseal cupping and fraying, widened physes, and indistinct zones of provisional calcification of the distal radius and ulna in c

the prevalence of vitamin D deficiency is common, radiographic evidence of any resulting bone disease is rare. Fractures resulting from the rachitic effects of vitamin D deficient rickets are also rare. Perez-Rossello et al. evaluated further the cohort from the Gordon et al. study. 35 of the 40 (88%) children found to have rachitic changes on imaging as a result of vitamin D deficiency were surveyed 2–3 years after their initial encounter. None of the children were found to have suffered a fracture as a result of the bone disease (Perez-Rossello et al. 2012). Clinical signs of vitamin D-deficient rickets coincide with the clinical signs expected with hypocalcemia. Decreased levels of serum calcium can cause

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Fig. 26 Expansion of the anterior ends of the ribs in a patient with rickets (arrows), producing the so-called rachitic rosary

decreased muscle tone, hypocalcemic seizures, and tetany. Some of the radiologic signs of rickets can be visualized clinically. Frontal and parietal bossing of the skull, along with the rachitic rosary of the ribs, can often be appreciated on physical exam. Bowing of the arms or legs in children developmentally capable of bearing weight on these limbs can also be readily apparent. Muscle weakness can lead to several different clinical complications, including delayed motor milestones, delayed eruption of primary teeth, and chest wall deformities and respiratory muscle weakness, leading to respiratory infections and respiratory insufficiency.

Hyperparathyroidism As mentioned previously, parathyroid hormone (PTH) increases osteoclastic activity in the bone, increasing serum calcium concentrations. Normally PTH is secreted in response to low plasma calcium levels, and its secretion is inhibited by elevated plasma calcium levels through an inhibitory feedback system. Certain pathologies can disrupt the proper regulation of PTH secretion. Primary hyperparathyroidism can be caused by parathyroid gland tumors that are not responsive to inhibitory feedback. Secondary hyperparathyroidism can be caused by chronic renal failure or vitamin D deficiency, both of which will decrease plasma calcium levels, triggering the parathyroid gland to increase PTH secretion. Hyperparathyroidism will stimulate osteoclasts in the bone, increasing bone destruction. It will also increase urinary excretion of phosphate and decrease renal

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Fig. 27 Early healing in a patient with rickets, in whom the zone of provisional calcification has become more distinct, appearing as a sclerotic line at the edge of the metaphysis

production of 1,25-dihydroxycholecalciferol. Mild hyperparathyroidism will not produce enough osteoclastic activity to weaken the bones, because the increased osteoclastic resorption is not enough to counteract the osteoblastic deposition of new bone. Severe hyperparathyroidism, however, will stimulate enough osteoclasts to outpace new bone production by osteoblasts, leading to significantly weakened bones (Guyton and Hall 2006). Radiographic analysis of the skeleton in a patient with severe hyperparathyroidism will demonstrate significant demineralization of the bones and possible fractures or cysts (Bandeira and Cassibba 2015). Laboratory analysis of patients with severe hyperparathyroidism will reveal elevated levels of PTH, elevated levels of calcium, elevated levels of alkaline phosphatase, decreased levels of vitamin D, and decreased levels of phosphate (Fig. 28).

Menkes Disease Menkes disease is due to a mutation in the gene ATP7A, which is responsible for the protein required for copper transport in enterocytes, placenta, and the central nervous

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Fig. 28 Two patients with hyperparathyroidism. Note ulnar metaphyseal irregularity and physeal expansion (arrow, a) and prominent bilateral proximal femoral metaphyseal irregularity and physeal widening (arrows, b), which could be misinterpreted as healing metaphyseal fractures

system (Bertini and Rosato 2008). This is a neurodegenerative disease that is usually fatal by 3 years of age if not treated appropriately. Symptoms present within the first few months of life and include generalized myoclonic seizures secondary to progressive cerebral degeneration, failure to thrive due to feeding difficulties, hypothermia, hypotonia, apnea, and abnormalities within the connective tissue of bones and blood vessels (Kaler 2013). Treatment with copper histidine can help delay the onset of symptoms if started within the first 2 months of life. The copper deficiency leads to poor collagen and elastin formation, leading to abnormal connective tissues within hair, blood vessels, and bone. The hallmark of the disease is kinky hair that is colorless and friable. Patients often have abnormal facies with chubby, rosy cheeks and a depressed nasal bridge. Patients will suffer from progressive psychomotor retardation and severe mental retardation. The blood vessels in Menkes patients are fragile and often rupture with minimal trauma or normal handling. The skeletal abnormalities include wormian bones within the sutures of the skull and abnormalities of the distal metaphysis of long bones with small spurs which can resemble classic metaphyseal lesions (Droms et al. 2017). The presence of unexplained intracranial bleeding, rib fractures, and metaphyseal abnormalities in a patient with Menkes disease could be mistaken for non-accidental trauma if healthcare providers are not familiar with the hallmark signs and symptoms of the disease (Figs. 29 and 30).

Scurvy Vitamin C (ascorbic acid) deficiency can lead to scurvy, a disease which affects the connective tissues of bones, blood vessels, skin, cartilage, and dentine. Vitamin C is

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Fig. 29 Pelvic and humeral radiographs in a patient with confirmed Menkes disease show typical metaphyseal spurs (arrows), which can be misinterpreted as classic metaphyseal lesions

Fig. 30 Kinky, colorless, friable hair seen in Menkes disease

necessary for collagen synthesis, cholesterol metabolism, neurotransmitter metabolism, and the synthesis of carnitine. Infants who consume unfortified formulas and boiled formulas (heat destroys vitamin C), or older children who do not consume the appropriate dietary amounts of vitamin C through fruit or juice, are at high risk of developing scurvy (Kliegman et al. 2016). Initial signs and symptoms of scurvy can be nonspecific with irritability, rash, and musculoskeletal pain; later symptoms include pseudoparalysis, fever, decreased appetite, and leg swelling. As the disease progresses, patients can develop bleeding of hypertrophied gums, cardiac hypertrophy, fragile hair often described as “corkscrew,” depression of the sternum, scorbutic rosary of the costochondral junctions of the ribs, perifollicular hemorrhage, bruising, and poor wound healing (Weinstein et al. 2001).

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The defect in collagen synthesis that is seen in scurvy leads to changes in the bones. Osteoblasts are not able to deposit osteoid, leading to thinning of the cortex of long bones and brittle bones that are easily susceptible to fracture despite little or no trauma. Radiographic changes can be seen at the distal ends of long bones, especially at the distal ends of the femurs. These signs are termed the white line of Frankel (a dense white line of provisional calcification located at the metaphysis); Pelkan spur (spurs of the metaphyseal cortex); and Trummerfeld zone (a transverse radiolucent band parallel to the white line of Frankel) (Golriz et al. 2017). The thin, dense cortex, generalized osteopenia, and atrophied trabeculae lead to a ground-glass appearance of the shafts of the long bones outlined by a “pencil-point” cortex (Kliegman et al. 2016). Periosteal reaction, which in healthy children is often evidence of healing fractures, can be seen in patients suffering from scurvy due to subperiosteal hemorrhage, the result of minimal trauma or normal handling (Golriz et al. 2017) (Fig. 31). The multiple skeletal changes and abnormalities that can be seen with scurvy can easily be mistaken for evidence of non-accidental trauma. Patients with scurvy are at risk for intracranial and ocular bleeding (most often involving the conjunctiva), which can also be confused with abusive trauma (Kliegman et al. 2016). There are no validated laboratory tests for this vitamin deficiency. The diagnosis often rests on

Fig. 31 Patient with scurvy demonstrating several typical radiographic findings, including the sclerotic white line of Frankel (black arrows), lucent Trummerfeld zones (white arrows), Pelkan spurs at the edges of the metaphyses (arrowhead), Wimberger’s ring (ring epiphyses), and cloaks of periosteal new bone formation from subperiosteal hemorrhage

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the clinical and radiologic findings, the dietary history, and the quick resolution of symptoms in response to vitamin C supplementation.

Caffey Disease Caffey disease, also known as infantile cortical hyperostosis, is a rare disorder thought to be the result of a mutation in the COL1A1 gene (Nistala et al. 2014). Prenatal and postnatal cases of Caffey disease have been reported; however, the disease most commonly presents between 10 weeks and 6 months of life (Kliegman et al. 2016). The disease is characterized by inflammation and painful deposition of new subperiosteal bone, causing irritability, swelling of the affected area, and fever (Navarre et al. 2013). Radiographic imaging demonstrates soft tissue swelling and subperiosteal bone formation, which could easily be mistaken for a healing fracture (Kamoun-Goldrat and le Merrer 2008). The most commonly affected bone is the mandible. This disease is self-limiting and does not recur. There is a known genetic link in some cases; however, sporadic cases have also been noted (Nistala et al. 2014). Autosomal dominant and autosomal recessive inheritance patterns have been identified, but a lack of family history does not exclude the diagnosis (Fig. 32).

Osteomyelitis Osteomyelitis is a bacterial infection of the bone. The symptoms and radiographic findings of osteomyelitis can be confused with trauma. The symptoms can vary, depending upon the age of the child. Neonates may not develop typical signs of infection such as fever, and the only symptom displayed by a neonate may be refusal

Fig. 32 Infant with Caffey disease demonstrating prominent periosteal reaction and soft tissue swelling along the mandible (a), left radius (b), and left tibia (c). The periosteal reaction tends to involve the diaphysis and spare the metaphysis and epiphysis in the long bones, as seen in this case

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to move the affected body part. Older children will often develop fever, pain, swelling, and erythema at the site of the infection. Ambulatory children may refuse to walk or bear weight on a leg if the affected area is part of a lower extremity. Physical exam may demonstrate focal or point tenderness, which is also highly suggestive of fracture. If the infection affects the metaphysis of long bones, radiographic findings can be confused with classic metaphyseal lesions. Laboratory analysis and evaluation with additional imaging such as MRI may be helpful in distinguishing infection from trauma when the clinical picture is not specific (Kliegman et al. 2016) (Fig. 33).

Other Causes Several other disease processes and chronic illnesses can affect bone health as well. Many children with complex, multifaceted diseases (cystic fibrosis, inflammatory bowel disease, neuromuscular disorders such as cerebral palsy and spina bifida, liver disease, chronic kidney disease, etc.) have a significantly increased risk of poor bone health due to immobility, malabsorption, lack of optimal nutrition, and vitamin deficiencies (Williams 2016). Immobility will place a patient at increased risk for bone demineralization secondary to disuse. As mentioned previously, bone Fig. 33 Infant with chronic osteomyelitis of the tibia. Note mixed lucency and sclerosis within the proximal tibia (arrow) and cloak of periosteal reaction at the proximal metaphysis (arrowheads), which could be misinterpreted as evidence of healing fracture

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production is dependent upon the stress placed upon the bone. Immobility prevents the weight bearing stresses required to optimize bone metabolism. Many patients suffering from chronic diseases have periods of anorexia due to the disease process itself or side effects from medication. Many patients with chronic disease require various types of tube feeding or parenteral nutrition for extended periods of time. Although the nutrition provided through these mechanisms is nutritionally optimized, it does not always perfectly meet the dietary requirements of the patient. Complications with tube feedings, parenteral nutrition, and the various feeding equipment required do arise and can be detrimental to the already imperfect nutrition. Some diseases such as hyperthyroidism, cystic fibrosis, liver disease, and growth hormone abnormalities will affect the metabolism of vitamins and minerals necessary for optimal bone health (Williams 2016). Thyroid hormone stimulates bone resorption. Consequently, hyperthyroidism increases bone resorption to a detrimental degree, inducing osteoporosis and fragile bones. Liver disease and cystic fibrosis alter the body’s ability to properly absorb fat, which means that patients with liver disease or cystic fibrosis also have difficult absorbing fat-soluble vitamins such as vitamin D. Regular evaluations for nutritional status, laboratory analysis of vitamins and minerals, and bone mineral studies are required for patients who suffer from certain disease processes or chronic illnesses. Suffering from a chronic illness or an illness that can greatly affect bone health does not preclude non-accidental trauma. Abusive trauma should remain on the differential for any patient with a chronic illness, but a good understanding of the illness and its effects on bone health is necessary when determining the risk of non-accidental trauma. Congenital infections such as syphilis can also produce osseous changes that can mimic non-accidental trauma radiographically. The bones are often involved in syphilis, although the radiographic changes may not be immediately evident. Typical imaging findings of congenital syphilis include metaphyseal lucency which may be a response to systemic infection and/or deposition of syphilitic granulation tissue. The classic Wimberger sign of congenital syphilis refers to destructive lytic foci in the metaphyses of tubular bones, particularly the tibia. The metaphyseal destructive lesions can lead to pathologic fractures which mimic non-accidental trauma. Later in the disease course, diaphyseal involvement with destructive cortical lesions and periosteal reaction can be seen (Coley 2013) (Fig. 34).

Iatrogenic Agents Several iatrogenic agents can lead to skeletal changes, which could be confused with non-accidental trauma. Prolonged use of glucocorticoids, methotrexate, antiepileptic drugs, and prostaglandin E along with vitamin A toxicity can all have effects on bone health (Kliegman et al. 2016). Glucocorticoids decrease serum calcium through their action on the calcium absorption and reabsorption at the level of the intestines and

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Fig. 34 Two patients with congenital syphilis. Note lytic destructive lesions of the metaphyses (arrows, a and b), more pronounced in patient b, which can lead to pathologic fractures that mimic non-accidental trauma. Periosteal reaction is also present in b (arrowheads), which can be misinterpreted as resulting from healing fracture

kidneys (respectively), resulting in increased parathyroid hormone secretion (Compston 2018). Long-term glucocorticoid use results in a decrease in the number and activity of osteoblasts, which, when combined with the hyperparathyroidism, decreases bone deposition and leads to osteoporosis. Methotrexate, a folate antagonist commonly used to treat rheumatic disease and malignancies, has been associated with increased fracture risk. It is thought that methotrexate is toxic to osteoblasts while increasing osteoclastic activity, which decreases bone formation, increases resorption, and leads to significant osteopenia (Kliegman et al. 2016). Antiepileptic drugs like phenytoin, phenobarbital, pyrimidine, and carbamazepine induce CYP450 enzymes that metabolize the active form of vitamin D (25hydroxyvitamin D), decreasing serum levels. Valproate can have direct effects on bone, parathyroid hormone and calcitonin, impairing bone health (Fong and Riney 2014). Prolonged use without appropriate supplementation can lead to vitamin D

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deficiency severe enough to cause rickets. Appropriate monitoring of calcium levels, vitamin D levels, and bone density is necessary with prolonged use of these antiepileptic agents. Prolonged use of prostaglandin E or chronic vitamin A toxicity can cause subperiosteal bone formation along with associated soft tissue swelling, similar to that seen in Caffey disease (Kliegman et al. 2016). Children fed elemental formulas may develop hypophosphatemia, which can result in demineralization of the bones and propensity to fracture (Gonzalez Ballesteros et al. 2017). Patients who receive long-term total parenteral nutrition (TPN) are at risk for hypocalcemia and hypophosphatemia, which may cause bone demineralization and increased fracture risk. An additional risk in patients on TPN is copper deficiency, which can occur after prolonged dependence on TPN and can be multifactorial, depending on the copper stores in the body prior to TPN and the amount of copper supplied in the parental nutrition. Copper deficiency can manifest with a number of bony changes that may mimic those of non-accidental trauma, including metaphyseal spur formation, periosteal reaction, and fractures (Shaw 1992; Shike 2009) (Fig. 35).

Fig. 35 Two patients with copper deficiency secondary to TPN. Both patients show similar findings, including metaphyseal beaks and spurs (arrows, a and b) which can mimic classic metaphyseal lesions and cloaks of irregular periosteal reaction (arrowheads)

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Novel Theories Several theories have been proposed which attribute abusive fractures to “temporary brittle bone disease” (TBBD) from in utero confinement or “healing rickets.”

“Temporary Brittle Bone Disease” Paterson et al. first proposed temporary brittle bone disease as a hypothetical cause of fractures in infants in 1993 (Paterson et al. 1993). The hypothesis sought to provide a pathological explanation for fractures in infants with no other clinical sign of injury who did not meet diagnostic criteria for osteogenesis imperfecta. The study proposed copper deficiency as a possible cause of the brittle bone disease, but the results did not support the theory, citing most infants with low levels of serum copper were thriving with no radiological evidence of fracture. Most infants with fractures had normal levels of copper, which Paterson et al. suggest is due to a delay in bone recovery from a previous deficiency; however, the authors fail to provide a single example of a patient with documented copper deficiency who suffered a fracture after initiation of treatment. Shaw et al. demonstrated that radiographic changes, including symmetric cupping and fraying of metaphysis, osteopenia, subperiosteal new bone, and delay in bone age, preceded the fracture in infants with copper deficiency (Shaw 1988). No skull fractures have ever been reported in copper deficiency, and no rib fractures have been reported in a full-term infant with copper deficiency. It was also shown that treatment with copper leads to a full resolution of skeletal abnormalities and fractures never occur as a late sequel to copper deficiency. Paterson also proposed TBBD as the cause of infant fractures, negating trauma as a possible cause due to equating the absence of cutaneous injury at the site of the fracture site to a lack of trauma (Paterson et al. 1993). However, research has shown that it is very common for fractures to occur without associated bruising (Mathew et al. 1998; Peters et al. 2008). Further evidence put forth by Paterson et al. for TBBD was that the fractures attributed to TBBD were not painful and therefore often found incidentally on imaging (Paterson et al. 1993); however, it is well known among clinicians that fractures cause pain at the time of injury. The most common fractures that Paterson found in his TBBD patients were rib and metaphyseal fractures, which are both fractures having high specificity for abuse. Temporary brittle bone disease is not accepted by the broader medical community, and a critical review of the theory reveals that there is no basis to show that an underlying pathology in the bony matrix or that copper deficiency causes this hypothetical disease (Mendelson 2005). The use of unsupported scientific theories such as TBBD to explain non-accidental trauma is dangerous for a variety of reasons. Providing an unfounded theory to explain possible non-

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accidental trauma places the patient at extreme risk for continued abuse and even death. It should be noted that within the clinical practice of medicine, there is little controversy regarding the validity of TBBD. In the world of clinical medicine, it is understood that TBBD is a flawed theory with no evidence to substantiate its claims. It is only within the legal system that TBBD is represented as a plausible theory.

“Healing Rickets” There is small subset of providers in the medical community who advocate that the fractures seen in child abuse, including CMLs, are due to metabolic bone disease such as rickets, rather than abuse. Ayoub et al., are some of the most well-known proponents of this position (Ayoub et al. 2014). The Society for Pediatric Radiology (SPR) has condemned Ayoub et al.’s theory (Mendelson 2005). Wood wrote about the dangers of unsupported theories, stating “Failure to recognize and respond accordingly to cases of possible physical abuse places infants and children at risk of serious and potentially fatal injuries. Statements to the contrary such as those by Ayoub et al, have the potential to negatively affect the welfare of a group of vulnerable children and infants, whose interests pediatricians and caregivers are committed to defend” (Wood 2014). Although Ayoub et al. theorized that CMLs could be due to healing rickets, there has been no evidence to support this claim (Ayoub et al. 2014). Perez-Rossello et al. performed radiologic and histologic examination of nine deceased infants who had suffered a head injury. At least one CML and additional (non-CML) fractures were present (Perez-Rossello et al. 2015). Radiologic and histologic studies of the infants demonstrated no evidence of rickets and provided support that CMLs are commonly found in abused children. Additional studies such as the research performed by Thackeray et al. also supported these findings (Thackeray et al. 2016). Thackeray et al. performed a retrospective multicenter study that evaluated 119 children 12 months of age who were found to have a CML. Ninety-five percent of these children had at least one additional injury, 84% had an additional fracture, 27% had traumatic brain injury, and 43% had cutaneous injuries, thus demonstrating the association of CMLs with abuse. It has been found that the radiologic appearance of CMLs differs from the metaphyseal changes and fractures seen in rickets (Chapman et al. 2010). Fractures in the metaphysis are very uncommon in vitamin D-deficient rickets. In vitamin D-deficient rickets, there is an abnormal increase in unmineralized osteoid, providing the metaphysis with a higher plasticity. This increased plasticity and compliance serves as a protective factor, allowing the metaphysis to bend and not break. The metaphyseal fractures in children with rickets occurred toward the diaphysis and did not resemble CMLs. Metaphyseal fractures identified in children suffering from vitamin D-deficient rickets were accompanied by other characteristic findings such as fraying and cupping of the metaphysis (Chapman et al. 2010).

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“Temporary Brittle Bone Disease” from In Utero Confinement In 1999, Miller and Hangartner published an article entitled “Temporary brittle bone disease: association with decreased fetal movement and osteopenia” (Miller and Hangartner 1999). The premise of their hypothesis is that if the developing fetus has limited movement due to oligohydramnios, multiple gestation or anatomic changes in the uterus and placenta, there is decreased mineralization of the skeleton which leads to increased fracture risk in the infant. A review article published in 2005 by Mendelson details the fallacies in both the original temporary brittle bone disease publication and Miller’s theory (Mendelson 2005). Mendelson details how Miller’s conclusion was based on bone densitometry values without validated controls and an incorrect application of a previously published study of newborns with neuromuscular diseases that specifically states that normal newborns who had decreased intrauterine movement due to oligohydramnios did not exhibit decreased bone density (Rodriguez et al. 1988). As with TBBD, this more recently described hypothesis is also viewed as a flawed theory in the medical community.

Ehlers-Danlos Syndrome Ehlers-Danlos syndrome (EDS) is a group of connective tissues disorders believed to be from abnormal collagen function (Kliegman et al. 2016). The physical manifestations of the disorder are soft, pliable skin that has poor wound healing as well as joint hypermobility. In 2017, Holick published a case series of 72 infants, all less than 1 year of age, who were initially diagnosed with abuse and then referred for further evaluation at the Bone Health Care Clinic at Boston University (Holick et al. 2017). 93% of the patients were diagnosed with EDS (three were diagnosed with Ehlers-Danlos/osteogenesis imperfecta overlap syndrome, which is a diagnosis of Holick’s creation), and the remaining 7% were diagnosed with vitamin D deficiency. Of the 72 infants in the study, 45 (63%) had rib fractures, and 13 (18%) had classic metaphyseal lesions. The authors concluded that EDS, Ehlers-Danlos/osteogenesis imperfecta syndrome, and vitamin D deficiency are all associated with increased propensity to fracture in infants and these infants could be misdiagnosed as being victims of child physical abuse. A 2019 retrospective (1976–2015), population-based (8 county region in southern Minnesota), case-control study by Rolfes investigated whether EDS caused increased likelihood of fracture in infants and children (Rolfes et al. 2019). They identified 219 potential cases and were able to obtain complete records for the first year of life in 21 of the patients to make a diagnosis of EDS. None of the EDS patients had a fracture in the first year of life; however, 52% of EDS patients had fractures in childhood (1–18 years) compared to the control group, with a 24% fracture occurrence. Analysis of study data revealed an odds ratio of 3.4 (95% CI; 1.20–9.66) when children over 1 year of age with EDS were compared to controls. This means that children with EDS who are over 1 year of age are 3.4 times more likely to have a fracture than children without EDS. The fractures that the EDS

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patients sustained during childhood were of the long bones, clavicles, or fingers with an acute presentation and appropriate trauma history. The authors concluded that there was not any evidence that infants with common forms of EDS had increased propensity to fracture and that mobile children may have a higher incidence of fractures. The conclusions from these two studies are starkly different, with the Holick study suggesting that infants less than 1 year of age with EDS have an increased propensity to fracture, but the Rolfes study reached the opposite conclusion. In the Holick analysis, the EDS diagnostic criteria were improperly applied, whereas in the Rolfes study, systematic application of the EDS diagnostic criteria was used to verify the EDS diagnosis. All of the children in the Holick study were under 1 year of age, with many fractures having a high specificity for abuse (rib, metaphyseal fractures). In contrast, the Rolfes study did not find any fractures in children less than 1 year of age. In the children with EDS who had fractures, the fractures were low specificity fractures with an explanatory injury history. One must closely examine the methods of each study and also evaluate for any potential bias when assessing the authors’ conclusions. In doing so, one can recognize the flaws in the theory that EDS causes infants less than 1 year of age to have increased fractures.

Medical Evaluation As previously mentioned, obtaining a thorough history of present illness, a full understanding of the developmental capabilities of the patient, and a complete medical history are imperative when evaluating a patient who has sustained a fracture. If a child is not developmentally capable of inflicting the injury or is immobile, the caregiver should be able to provide a history of the events that occurred surrounding the injury. If no history is provided or the history provided cannot account for the injury sustained, the suspicion of non-accidental trauma should be increased.

Obtaining History As previously mentioned, obtaining a thorough history of present illness, a full understanding of the developmental capabilities of the patient, and a complete medical history are imperative when evaluating a patient who has sustained a fracture. If a child is not developmentally capable of inflicting the injury or is immobile, the caregiver should be able to provide a history of the events that occurred surrounding the injury. If no history is provided or the history provided cannot account for the injury sustained, the suspicion of non-accidental trauma should be increased. If the injury was witnessed, all who were present should be interviewed separately and their stories compared. If the child who has suffered the injury is verbal, he

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or she should be interviewed separately as well. If there appears to be a delay in seeking care for an obvious injury, or if the stories provided by the caregiver and the child are not consistent with one another, concern for non-accidental trauma should remain high. History regarding the onset of symptoms is important and can be helpful when establishing a timeline for the injury. It is important to note that rib fractures and CMLs are often incidental findings among abused children. Fractures are known to be painful at the time of injury, as any movement that shifts the pieces of broken bone makes them rub against each other. Due to the anatomy of the ribs and the metaphyses, once the initial fracture has occurred, the fracture experiences minimal movement. Rib fractures and CMLs are known to be very painful at the time of injury; however, the pain experienced after the initial injury is entirely dependent upon the manipulation of the fractures. A complete past medical history is important, starting with pregnancy and delivery for any infants or toddlers. It is important to include the child’s diet as an infant, any medications or supplementation, and knowledge of any radiographic studies that may have been performed prior to discharge from the hospital after birth. A full understanding of any health issues, disease processes, or chronic illnesses will provide further information about the patient’s bone health, along with any medications or therapies that the patient is receiving. It is also important to understand any emergency or urgent medical care that the patient has received in the past, including any previous injuries, bruises, or fractures sustained, and the cause of these injuries. A detailed family history can provide information about possible genetic diseases or syndromes that could contribute to poor bone health such as maternal vitamin D deficiency during pregnancy, osteogenesis imperfecta, and Caffey disease. A complete psychosocial history is also important and may identify risk factors for abuse such as financial insecurity, intimate partner violence, previous involvement with child protective services, substance abuse, and mental health issues. A thorough social history also provides pertinent details about various caregivers and the home environment.

Physical Examination A thorough physical examination is required for any patient with a fracture and concern for non-accidental trauma, including a complete skin exam and genital exam. For any child under the age of 4 years, the TEN-4 rule can be helpful when evaluating concerning skin findings (Pierce et al. 2010). Bruising of the torso, ears, and neck of any child under the age of 4 years is highly concerning for nonaccidental trauma due to the protected location of these body areas. Any bruising anywhere on the body of a child 4 months old or younger is highly concerning for abuse, as these children are not developmentally capable of self-inflicting such injuries. The physical exam can also provide information about any medical pathology that may place the child at an increased risk of fracture. The colorless kinky hair of

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Menkes disease, the blue sclera of osteogenesis imperfecta, or any immobility combined with G tube dependence should be considered. Findings of medical pathology should not negate any concerns for non-accidental trauma, but it should increase the concern for pathologic fractures.

Laboratory Analysis The various histories provided along with the results of the physical exam should guide the laboratory and radiologic evaluations. Basic trauma laboratory analysis will evaluate for any intra-abdominal trauma and includes blood work for a complete blood count, comprehensive metabolic panel, lipase, amylase, and urinalysis. If a patient has suffered extensive bruising, it would be helpful to obtain a creatine kinase level as well. When multiple fractures are identified, obtaining serum levels of parathyroid hormone, ionized calcium, vitamin D, phosphorus, and magnesium is also indicated to further evaluate bone health. Significant abnormalities with any of these labs may prompt an endocrinology consult for assistance with treatment and follow-up. If family history and physical exam are suggestive of osteogenesis imperfecta, laboratory analysis of COL1A1 and COL1A2 along with a genetics consult would be beneficial for further evaluation.

Radiology Radiographic imaging should be obtained whenever there is clinical concern for a fracture. If a fracture or concerning bruise/skin finding is identified in a child younger than 2 years of age, a complete skeletal survey should be obtained. A skeletal survey consists of a minimum of 20 images of the patient’s body, including images of every bone. A “baby gram” (an AP image of an infant’s entire body) is not sufficient to evaluate for non-accidental trauma; neither is a partial skeletal survey that does not include the appropriate 20 images. The American College of Radiology (ACR) and Society for Pediatric Radiology have published joint guidelines regarding the recommended imaging workup for suspected child abuse, as well as the appropriate imaging techniques (Wootton-Gorges et al. 2017). Skeletal surveys should be obtained by a radiology department that is skilled and experienced at performing such studies and should be interpreted by a trained pediatric radiologist (Fig. 36). Skeletal surveys should be read by a pediatric radiologist (a radiologist who has completed a pediatric fellowship and is trained to understand the unique characteristics of the immature skeleton). When evaluated by a radiologist who does not specialize in Pediatrics, there is an increased risk that certain findings will be misinterpreted as abusive injuries or as benign findings when, in fact, the opposite is true (Karmazyn et al. 2019). Misinterpreting injuries as abusive or accidental can have detrimental effects for the child and family, making the pediatric radiologist indispensable when evaluating skeletal surveys.

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Fig. 36 Standard radiographs included in the skeletal survey, adapted from the ACR-SPR Practice Parameter Skeletal Survey (ACR-SPR 2016). Complete skeletal surveys allow appropriate assessment of the entire skeletal system, including multiple views of various bones, ensuring the necessary evaluation of more subtle but concerning signs of abuse such as classic metaphyseal lesions. Skeletal surveys may be beneficial in children older than 2 years of age with limited developmental capabilities. Skeletal surveys of children 5 years and older have not been shown to be beneficial

It is important to note that more subtle, acute bone fractures may not be apparent until the bone displays signs of healing, which can take approximately 10–14 days after the initial presentation. A repeat skeletal survey is often required for further evaluation of bony injury or detection of injuries present but not visible on the initial skeletal survey (Barber et al. 2015; Harper et al. 2013). The repeat skeletal survey is best obtained approximately 2 weeks after the initial study and may provide information about additional injuries that were not apparent on the first study. The age of a fracture is a frequent and unfortunately often frustrating question in cases of child abuse. Ability to precisely date when a fracture occurred can be helpful in identifying a potential abuser. The radiographic findings encountered during fracture healing unfortunately do not lend themselves to such precision. Multiple studies have found variability in the appearance and timing of healing changes (Islam et al. 2000). The earliest finding of fracture healing is periosteal reaction, which is generally seen 7–10 days following the injury (Prosser et al. 2012). Before this point, the fracture can be considered “acute,” but having occurred sometime within the last 7 days. Soft callus formation is seen approximately 10–21 days after the injury. Further maturation of the callus, loss of a distinct fracture line, and remodeling of the bone at the fracture site occur over the next weeks to months (Kleinman and Walters 2015) (Figs. 37, 38, and 39). Intracranial imaging, including computed tomography scans (CT scans) or magnetic resonance imaging (MRIs), can be helpful for further evaluation of possible trauma. Any infant who is less than 6 months of age and is found to have a fracture should undergo intracranial imaging to evaluate for possible intracranial trauma. Any child who has concern for possible abuse and liver enzymes (AST and ALT) greater than 80 should undergo an abdominal/pelvis CT for further evaluation of

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Fig. 37 Accidental injury in young child with acute distal tibial fracture (a) and follow-up x-rays 2 weeks later showing development of early healing changes with periosteal reaction (arrows, b)

abdominal and pelvic trauma. CT scans of the chest are also helpful in visualizing rib fractures, especially acute rib fractures.

Sibling Evaluation It is also important to evaluate the siblings of the patient when there is significant concern for non-accidental trauma. Any siblings who reside in the same home or are cared for by the same caregivers should undergo an evaluation for non-accidental trauma. The type of evaluation is dependent upon the sibling’s age and development and follows the same guidelines proposed for the index case. If a sibling is under the age of 2 years, the sibling should also receive a thorough physical exam and skeletal survey. Older, developmentally capable children should undergo a thorough physical exam for any possible signs of non-accidental trauma. Diagnosing non-accidental trauma can be a complex and involved process, requiring the interaction of healthcare providers, law enforcement, social workers, and child protective services. A thorough and complete evaluation is required for any patient who has suffered a fracture or other injury that is concerning for abuse. Child abuse pediatricians, along with other subspecialists (Genetics, Orthopedics,

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Fig. 38 Child with multiple non-accidental injuries, including distal tibial and fibular fractures which are acute in a (arrows) and show typical chronic healing changes several months later in b, with sclerosis and remodeling at the fracture sites

Endocrinology, etc.), may be helpful in guiding the evaluation and treatment of the patient. All healthcare providers are deemed mandatory reporters and should be familiar with the local laws governing their state. It is important to note that reporting is mandatory for any suspected non-accidental trauma and does not require concrete proof of abuse or neglect. The suspicion of non-accidental trauma alone is enough to make a report to child protective services. Failure to take the appropriate and necessary action required when abuse is suspected places the child at serious risk for further abuse. Research has shown that in more than a quarter of confirmed physical abuse cases, the child was a victim of abuse repeatedly, and over time the violence escalated (Sheets et al. 2013). Early identification and intervention are necessary to ensure the safety and well-being of the child.

Key Points • Fractures are the second most common type of physical injury due to abuse. • Bone health is complex and affected by multiple factors such as genetics, nutrition, age, sex, activity level and muscular strength, and medications.

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Fig. 39 Multiple classic metaphyseal lesions (CML) in various stages of healing in the same patient. Acute distal tibial CML (“bucket handle type”) in a (arrow); distal right femoral CML (“corner fracture type”) in b (arrows) with early periosteal reaction (arrowhead); distal left femoral CML in c (arrows) with slightly more advanced healing, including sclerosis at the fracture site and more extensive periosteal reaction (arrowheads)

• There are multiple fracture morphologies, including greenstick fractures, buckle fractures, classic metaphyseal lesions, transverse fractures, spiral fractures, and oblique fractures. • The various fracture morphologies are created by different biomechanical forces. Understanding the biomechanics required to create a specific fracture is necessary when evaluating the plausibility of a reported history. • Certain fractures have different specificities for non-accidental trauma. • Fractures with a high specificity for abuse include classic metaphyseal lesions, rib fractures, scapular fractures, spinous process fractures, and sternal fractures. • Fractures with a moderate specificity for abuse include multiple fractures (especially bilateral), fractures of different ages with various stages of healing, epiphyseal separations, vertebral body fractures and subluxations, digital fractures, and complex skull fractures. • Fractures that are commonly seen and have a low specificity for abuse include subperiosteal new bone formation, clavicular fractures, long-bone shaft fractures (e.g., toddler’s fracture) in ambulatory patients, and linear skull fractures.

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• There are multiple disease processes, deficiencies, and even iatrogenic causes of bone demineralization which can lead to weakened bones such as osteogenesis imperfecta, vitamin D deficient rickets, hyperparathyroidism, Menkes disease, scurvy, Caffey disease, osteomyelitis, iatrogenic agents, and other chronic, complex diseases. • Novel theories such as temporary brittle bone disease have been proposed to explain non-accidental fractures. This theory is unfounded with no scientific evidence to support it. • When non-accidental trauma is suspected, a full medical workup should be conducted to further evaluate the concern. This medical workup relies on a thorough history, physical examination, and often laboratory analysis and radiographic imaging.

Conclusion Fractures in the pediatric population occur when external forces are placed on the skeleton through either accidental or inflicted mechanisms. A variety of predisposing factors exist that can make bones more susceptible to fracture. Because child physical abuse can potentially occur to any child, it is imperative that child abuse is on the differential diagnosis when a fracture is detected. The clinician should obtain a thorough history, perform a complete physical examination, obtain laboratory and radiographic studies, and consult with specialists (child abuse pediatricians, pediatric radiologists, medical geneticists) in order to ensure a proper diagnosis for the etiology of the fracture(s). Collaboration with investigative agencies is a critical element in obtaining a history of injury and verifying information provided.

Summary Child physical abuse is an unfortunate reality in society, with fractures being the second most common injury associated with child abuse (Flaherty et al. 2014). Due to the unique characteristics of pediatric bones, certain fracture morphologies (CML, greenstick, buckle) are only seen in the pediatric population. The trauma history, or lack thereof, must always be taken into account when assessing the accidental versus non-accidental nature of a fracture, as fracture type alone cannot determine the causation of the injury. The developmental capabilities of the infant or child must also be considered when assessing the plausibility of the proposed mechanism for the fracture. When making an assessment for possible physical abuse, the clinician should evaluate for any underlying predisposition to fracture (metabolic bone disease, genetic conditions, chronic medical conditions, etc.) by obtaining a thorough history, physical examination, laboratory evaluation, and radiographic studies. Child abuse pediatricians, pediatric radiologists, and medical geneticists should be consulted as needed during the evaluation.

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Cross-References ▶ Abusive Burns ▶ Abusive Head Trauma: Understanding Head Injury Maltreatment ▶ An Introduction to Child and Youth Maltreatment: Consequences and Considerations ▶ Bruising in Suspected Child Maltreatment ▶ Child and Youth Fatality Review ▶ Child Physical Abuse: A Pathway to Comprehensive Prevention ▶ Corporal Punishment: Finding Effective Interventions ▶ Corporal Punishment: From Ancient History to Global Progress ▶ Domestic Child Torture: Identifying Survivors and Seeking Justice ▶ Inflicted Thoracoabdominal Trauma ▶ Overview of Child Maltreatment ▶ Parents Who Physically Abuse: Current Status and Future Directions

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Ropp, A. M., & Davis, D. L. (2015). Scapular fractures: What radiologists need to know. American Journal of Roentgenology, 205(3), 491–501. https://doi.org/10.2214/AJR.15.14446. Shaw, J. C. (1988). Copper deficiency and non-accidental injury. Archives of Disease in Childhood, 63(4), 448–455. https://doi.org/10.1136/adc.63.4.448. Shaw, J. C. (1992). Copper deficiency in term and preterm infants. In Nutritional anemias. New York: Vevey/Raven Press. Sheets, L. K., Leach, M. E., Koszewski, I. J., Lessmeier, A. M., Nugent, M., & Simpson, P. (2013). Sentinel injuries in infants evaluated for child physical abuse. Pediatrics, 131(4), 701–707. https://doi.org/10.1542/peds.2012-2780. Shike, M. (2009). Copper in parenteral nutrition. Gastroenterology, 137, S13–S17. Thackeray, J. D., Wannemacher, J., Adler, B. H., & Lindberg, D. M. (2016). The classic metaphyseal lesion and traumatic injury. Pediatric Radiology, 46(8), 1128–1133. https://doi.org/ 10.1007/s00247-016-3568-0. Thompson, A., Bertocci, G., Kaczor, K., Smalley, C., & Pierce, M. C. (2015). Biomechanical investigation of the classic metaphyseal lesion using an immature porcine model. American Journal of Roentgenology, 204(5), W503–W509. https://doi.org/10.2214/AJR.14.13267. Tournis, S., & Dede, A. D. (2018). Osteogenesis imperfecta – A clinical update. Metabolism, 80, 27–37. https://doi.org/10.1016/j.metabol.2017.06.001. Tsai, A., Connolly, S., Ecklund, K., Johnston, P., & Kleinman, P. K. (2019). Subperiosteal new bone formation with the distal tibial classic metaphyseal lesion: Prevalence on radiographic skeletal surveys. Pediatric Radiology, 49(4), 551–558. https://doi.org/10.1007/s00247-018-4329-z. Tsia, A., Coats, B., & Kleinman, P. K. (2017). Biomechanics of the classic metaphyseal lesion: Finite element analysis. Pediatric Radiology, 47(12), 1622–1630. https://doi.org/10.1007/ s00247-017-3921-y. Von Garrel, T., Ince, A., Junge, A., Schnabel, M., & Bahrs, C. (2004). The sternal fracture: Radiographic analysis of 200 fractures with special reference to concomitant injuries. Journal of Trauma, 57(4), 837–844. Wagner, C. L., & Greer, F. R. (2008). Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics, 122(5), 1142–1152. https://doi.org/10.1542/peds.20081862. Weinstein, M., Babyn, P., & Zlotkin, S. (2001). An orange a day keeps the doctor away: Scurvy in the year 2000. Pediatrics, 108(3), E55. Wilkins, K. (2005). Principles of fracture remodeling in children. Injury, 36(Suppl 1), A3–A11. Williams, K. M. (2016). Update on bone health in pediatric chronic disease. Endocrinology and Metabolism Clinics of North America, 45(2), 433–441. https://doi.org/10.1016/j. ecl.2016.01.009. Wood, B. P. (2014). Commentary on “a critical review of the classic metaphyseal lesion: Traumatic or metabolic?”. American Journal of Roentgenology, 202(1), 197–198. https://doi.org/10.2214/ AJR.13.11931. Wootton-Gorges, S. L., Soares, B. P., Alazraki, A. L., Anupindi, S. A., Blount, J. P., Booth, T. N., Dempsey, M. E., Falcone, R. A., Jr., Hayes, L. L., Kulkarni, A. V., Partap, S., Rigsby, C. K., Ryan, M. E., Safdar, N. M., Trout, A. T., Widmann, R. F., Karmazyn, B. K., & Palasis, S. (2017). ACR appropriateness criteria ® suspected physical abuse-child. Journal of the American College of Radiology, 14(5S), S338–S349. https://doi.org/10.1016/j.jacr.2017.01.036.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Burn Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Types of Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Thermal Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Radiant Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chemical Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Electrical Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Friction Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cold Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical Child Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scene Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Burn Mimics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Burns are a common injury in both abused and non-abused children, and the accurate diagnosis of abusive burns is important to ensure protection. This chapter will discuss the epidemiology and characteristics of abusive and accidental burns. The classification of burns as well as the different categories of burns – including thermal, radiant, chemical, and electrical burns – will also be reviewed

This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. M. S. Cantu (*) · J. S. Kondis Washington University School of Medicine, St. Louis, MO, USA e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_249

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and discussed in-depth. This chapter will explore the important history aspects to obtain and to aid in determining whether a burn is inflicted or accidental. The components of a burn scene investigation will be included. Other skin findings that can sometimes be confused with burns such as infections, cultural practices, and dermatitis will also be reviewed. Keywords

Thermal burn · Immersion burn · Splash burn · Contact burn · Flame burn · Radiant Burn · Electrical Burn · Chemical burn · Medical child abuse · Scene investigation

Introduction Burns are a common childhood injury. It has been estimated that 8 in 100,000 children are hospitalized with burns worldwide (Burd and Yuen 2005). Fire and burn injuries comprise approximately 5% of unintentional injury deaths and 2% of nonfatal injuries in children (Borse et al. 2009). Approximately 10,000 children were hospitalized for burns in the United States in 2000 (Shields et al. 2007). It has been reported that inflicted burns make up between 5% and 9% of abuse injuries (Degraw et al. 2010; Hight et al. 1979; Thombs 2008). Children with abusive burns have been found to have a higher mortality rate compared to those with accidental burns, even after adjusting for the child’s age and the size of the burn (Hodgman et al. 2016). Multiple studies have also found a child’s age and gender to be significant predictors of an abusive burn, with younger children and male children being more likely to have been victims of inflicted burns (Hodgman et al. 2016; Spinks et al. 2008). Scald burns are more common in children 2 years or younger, and flame/fire burns are more common in children 3 and older (Shields et al. 2007). Children who are 1-yearold are ten times more likely to suffer scald burns than school age children (Kemp et al. 2014). It has also been found that up until age 2, children are more likely to be burned if they have advanced gross motor skills and slow fine motor skills (Emond et al. 2017). In addition, children aged 5–11 are more likely to sustain a burn if they have a history of coordination problems (Emond et al. 2017). Recent studies have evaluated some of the common characteristics of children with burn injuries who have been reported to child protective services. Children who are not Caucasian, come from single parent homes, use Medicaid insurance, and have had prior child protective service involvement are more likely to be reported (Campos et al. 2017).

History A thorough history is important when there is concern that a burn may be inflicted. Information collected should include the location where the burn occurred; the specific event(s) leading to the injury; who was present; what clothing the child

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was wearing; and the amount of time between the injury and presentation to care. Studies have shown that there are certain historical aspects that are more predictive of abuse. An injury that is inconsistent with the history given, a delay in seeking care for the injury, an unknown mechanism, and the existence of multiple conflicting stories of the event are all predictive of abuse especially if more than one of these is present (Hammond et al. 1991). Another study evaluated the features that were more likely to indicate an intentional scald and found the following predictors: associated unrelated injury, coexisting fractures, a passive/introverted fearful child, numerous prior accidental injuries, if a sibling was blamed for the scald, a history of previous abuse, and domestic violence (Maguire et al. 2008). It is also important to collect a history in regard to the developmental capabilities of a child and to give careful consideration to the proposed mechanism of injury and the child’s abilities. Normal childhood development is a spectrum, and one child may have more advanced skills than another. In one study, a standard bathtub was installed in a pediatric clinic and observed children between 10 and 18 months attempt to climb into the tub (Allasio and Fischer 2005). It found that 35% of the children who attempted were able to get into the tub (Allasio and Fischer 2005). There have also been studies performed in the development of a clinical prediction tool to aid in the assessment of children who have suffered burns. The variables studied included the child’s age;, whether the child is known to social services; the severity of the burn;, whether there is concern about the explanation; the location of the burn; concerns about supervision; pattern; the presence of multiple burn site;s if first aid was given prior to seeking medical care and if there was a delay in seeking medical care (Kemp et al. 2018). This tool was found to have a sensitivity of 84% and specificity of 80% in predicting children at risk for maltreatment (Kemp et al. 2018).

Medical Evaluation All children should undergo initial stabilization including assessment of their airway, breathing, and circulation. They should also undergo adequate fluid resuscitation based on the total body surface area involved in the burn. Adequate pain control is a cornerstone of therapy. A complete physical exam, including mucous membranes, should be performed to look for any other injuries. Photo documentation should also be obtained of the burns, both before and after the burns are debrided as burn depth and appearance can change with time (Hettiaratchy and Papini 2004). A recent study was performed to describe the characteristics and co-existent injuries of children who were burned and were referred to a child abuse pediatrician (CAP). Additional injuries were found in 24.2% of the children who were primarily being seen for a burn, with most of the other injuries being fracture or cutaneous injuries including bruises, lacerations, abrasions, and/or bites (Pawlik et al. 2016). A comparison was also made between the diagnostic evaluations of children who were burned and were referred to a CAP and children who had sustained other non-burn injuries and were referred to a CAP. The rates of diagnostic testing, including

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skeletal survey and the evaluation of hepatic transaminases, were lower in children with burns than in those with other injuries. However, the frequency of fracture and abdominal injury was comparable in both groups (Pawlik et al. 2016). Another study evaluating children with burns who were referred to a child abuse team found a fracture incidence of 14% on skeletal survey (Hicks and Stolfi 2007). Another similar study found the incidence of fracture to be 33% in children with suspected abusive burns (Fagen et al. 2015). These studies help to demonstrate the importance of a thorough evaluation for occult injuries in children in whom an abusive burn is suspected. Depending on the age of the child, this evaluation often includes a skeletal survey to evaluate for occult fracture, laboratory evaluation including pancreatic and liver enzymes, abdominal CT scan when there is concern for intraabdominal injuries, and head imaging to evaluate for intracranial injuries depending on the child’s age and mental status. A drug screen to evaluate for possible drug exposure can be helpful as well, especially when there is a delay in seeking medical care or when there is concern for caregiver drug abuse.

Burn Classification The skin is composed of three layers: the epidermis, the dermis, and the subcutaneous tissue. The epidermis is the outermost layer of the skin. The dermis is the layer underneath the epidermis and includes nerve endings, hair follicles, sweat glands, oil glands, and blood vessels. The subcutaneous tissue, also called the hypodermis, is comprised of connective tissue and fat and connects the epidermis and dermis to underlying tissues like the muscle or bone (Fig. 1). Burns are classified according to the depth of injury. Traditionally, the classification system used included first-degree, second-degree, third-degree, and fourth-

Fig. 1 Burn depth diagram (From: Hettiaratchy and Papini 2004)

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degree burns. Currently the classification system most often used includes superficial (formerly first degree), superficial partial thickness (formerly second degree), deep partial thickness (formerly second degree), and full-thickness burns (formerly third degree). Superficial burns only involve the outermost layer of the skin, which is called the epidermis. An example of a superficial burn is a sunburn without blisters. Superficial burns typically heal without any sequelae. Superficial partial-thickness burns include the epidermis and the superficial dermis. These burns blister, are painful, and blanch when pressure is applied. They do not typically scar. Deep partial-thickness burns include the epidermis and extend to the deep dermis. These burns are typically painful with pressure and do not blanch when pressure is applied. Deep partial-thickness burns usually cause scarring. Full-thickness burns affect the epidermis, dermis, and often extend into the subcutaneous tissue. These burns are usually painless due to nerve damage, do not blanch with pressure, and can heal with scarring and contractures. Fourth-degree burns include the epidermis, dermis, subcutaneous tissue, and involve deeper tissues such as the muscle or bone (Strobel and Fey 2018). Estimating the body surface area involved in burns is an important part of assessing a burn and providing treatment (Fig. 2). This estimation is used in the calculation of resuscitation fluids in the acute treatment of the burn and is used to aid in decision-making about referrals to burn centers. Higher body surface area involvement is associated with increased mortality; one study found that the mortality rate increased substantially at 60% total body surface area (Kraft et al. 2012). The most commonly used tool to aid in estimating body surface area in children is the modified Lund and Browder chart (Harwood-Nuss and Linden 1996). Estimating burn body surface area in children is different from the methods used in adults, as children have different body proportions compared to adults. The Wallace Rule of Nines is another frequently used tool to estimate burn body surface area but is not as accurate in children (Hettiaratchy and Papini 2004). Another method of estimating total body surface area of a burn is to compare the burn size to the size of the child’s palm. The palmar surface of a child’s hand is approximately equivalent to 1% of their body surface area (Nagel and Schunk 1997).

Types of Burns Thermal Burns Thermal burns are caused by contact with hot liquids, hot objects, flames, or steam. The depth of the injury is related to the time of contact with heat, the temperature of the object/liquid, and the skin characteristics including thickness and vascularity. Scald burns, specifically from tap water, are the most common abusive burn (Ojo et al. 2007; Maguire et al. 2008). One study found that about 28% of the tap water scald burns that were reviewed were thought to be secondary to abuse (Feldman et al. 1998). Immersion scald burns are one of the most common abusive scald burns (Daria et al. 2004). There are certain patterns that are more frequently found in abusive

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Fig. 2 Modified Lund and Browder chart (From Harwood-Nuss and Linden 1996)

burns. Simultaneous burns of both lower extremities, also known as mirror image burns, as well as buttock and perineal burns are found more often in abuse (Daria et al. 2004). Other patterns that have been previously described include sparing of the areas of skin of maximal flexion such as the inguinal crease or popliteal fossa and sparing of the central buttocks (Lenoski and Hunter 1977). The mechanism of sparing of the central buttocks and/or soles of the feet involves contact with the cooler surface of the container in which the child is immersed. This sparing pattern of the buttocks is sometimes referred to as a “doughnut-shaped” distribution of sparing (Lenoski and Hunter 1977) (Photo 1). Clear demarcation between injured and non-injured skin, without splash marks, and a uniform depth of burn, are concerning for forced immersion in hot water (Purdue et al. 1988). These burns are sometimes referred to as the “stocking” and “glove” distributions when they

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Photo 1 Sparing of buttocks, “donut” pattern from forceful immersion burn

Photo 2 “Stocking” burn distribution from dunking

involve the arms and legs (Purdue et al. 1988) (Photos 2 and 3). Careful analysis of areas of sparing alongside burned areas can allow the experienced examiner to determine how the child was positioned when they came into contact with hot water and also permit evaluation of the provided history. Accidental scald burns are most common in children around the age of one. The mechanisms most often involve the child reaching up to an elevated surface and pulling a container of hot liquid onto themselves, such as when a cup containing hot liquid is overturned (Drago 2005). Hot water splash burns require a minimum of 140  F (Alexander 2007). Such burns are typically located on the head, upper extremities, and/or torso. Splash burns often have a triangular appearance and are deeper at the initial site of impact with the skin. These burns become more superficial as the liquid cools when running down the body (Purdue et al. 1988). Clothing or diapers can also change the appearance of splash burns. While the presence of fabric may help to dissipate heat to some extent, some studies have

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Photo 3 “Glove” distribution to hand from dunking in hot water-inflicted burn

Photo 4 Accidental splash burn

shown that in some cases, fabric can also cause burns to become more severe by prolonging the heat supply (Log 2017). Another study found that the scalds sustained by school aged children are primarily the result of a spill from food or containers of hot water (Kemp et al. 2014). There have been many efforts to decrease the incidence of scald burns in children. One study found that the typical soup packaging used, a cup with a narrow base, was implicated in most of the scald burns caused by soup and recommended a change in packaging to manufacturers. (Palmieri et al. 2008) (Photo 4). Burns caused by hot solid objects, also known as contact burns, are another type of burn that can be either accidental or inflicted by abuse. Some commonly seen objects used in abusive burns include cooking and eating utensils, cigarettes, cigarette lighters, irons, space heaters, heating grates, and hair styling devices.

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Inflicted injury should be considered in cases in which the edges of the burns are sharply demarcated rather than indistinct or blurred in appearance, when there are multiple burns, when the burns are located in areas that are not typically exposed or injured through accidental means, or when there is any discrepancy between the child’s developmental ability and the provided history. When accidental, cigarette burns are often irregularly or “brush” shaped, located in areas of the body not typically covered with clothing, and are fairly superficial (Faller-Marquardt et al. 2008). Therefore, a grouping of clearly defined deep contact burns would be concerning for abuse. There are also multiple dermatologic conditions that are frequently confused with cigarette burns. These will be discussed in detail later in this chapter (Burn Mimics). In many instances, an accidental mechanism is provided for cigarette lighter burns. One recent study evaluated the time needed to heat a metal lighter to a temperature capable of inflicting a burn. When held upright a lighter would need to be heated for at least 50 s to cause a burn, which is longer than typically needed to light a cigarette (Harel et al. 2017). The same lighters then took less than 60 s to cool down to less than 60  C (140  F) (Harel et al. 2017), suggesting that a small child would not have the developmental capability to hold a lighter in the “on” position long enough to cause a patterned burn and also would not be able to cause a burn after a lighter had been turned off and placed down (Photos 5, 6, 7, and 8). Direct contact with flame/fire is yet another type of thermal burn. These burns are most commonly sustained in house fires and are more commonly seen in older children (Morrow et al. 1996). Victims of flame burns are also at risk of inhalation injury, especially if they are in an enclosed setting (Walker and King 2020). A study comparing scald burns and flame burns found that flame-burned patients had larger and deeper burns resulting in a higher mortality rate (Kraft et al. 2011).

Photo 5 Burn from the end of a hair styling tool

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Photo 6 Inflicted cigarette burn

Photo 7 Inflicted burn from cigarette lighter

There have also been reports of abusive flame burns including one study describing ten cases which involved holding a burning match to the child’s face or thigh (Mathangi Ramakrishnan et al. 2010). The in-home manufacture of illicit substances like methamphetamine also poses a risk of fire or explosion (see Photos 9 and 10).

Radiant Burns Radiant burns can be caused by ionizing radiation, UV light, or thermal radiation. The most common radiant burns are sunburns which are caused by UV light. Radiant burns can also be seen when caused by medical imaging or radiation therapy. Microwave oven burns are seen occasionally in children. There have been many instances when children have sustained burns after handling food or liquids placed in microwave ovens; there have also been reported incidents of infants being placed directly in microwaves (Alexander et al. 1987). Microwaves work to heat food by

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Photo 8 Contact burn from stepping on a hot grate

Photo 9 Patient, a teenage boy, sustained a flame burn after putting alcohol on a trash fire

exposing it to electromagnetic waves. This has a thermal effect on tissue. A pattern unique to microwave burns involves the sparing of fat due to the greater involvement of tissues with a high water content. In previous reports, biopsies have shown undamaged subcutaneous fat beneath burned epidermis and dermis as well as burned muscle underneath the fat (Alexander et al. 1987). Microwave ovens also have a

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Photo 10 Child sustained burns from a Meth lab explosion

Photo 11 Sun burn

tendency to heat unevenly, and there have also been reports of oropharyngeal burns of infants who were fed bottles that were heated in the microwave. One case described an infant that sustained severe facial and hand burns requiring amputation after being burned by hot milk that was heated in a microwave (Dixon et al. 1997; Photo 11).

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Chemical Burns Chemical burns are caused by skin contact with a caustic substance, often an acid or alkali (Photo 12). The primary mechanism of action involving chemical burns involves the denaturing of skin proteins and typically occurs over a longer period of time than thermal burns (Palao et al. 2010). Children are most likely to come into contact with household products such as drain cleaner, dishwashing detergents, laundry detergents, bleach, oven cleaners, hair products, cosmetics, or rust removers (Yin 2017). These substances can have direct contact with the skin or can be ingested. These exposures can happen accidentally, due to a lapse in or lack of supervision, or can be inflicted. The severity of the burn is dependent on the length of time the substance was in contact with the skin, the chemical concentration, the quantity of the chemical involved in the exposure, the chemical’s mechanism of Photo 12 Bleach burn. Child was sitting in car seat, and older sibling poured bleach on him. Area with diaper on was spared

Photo 13 Burn from child who ingested a large amount of chocolate-flavored Senna-containing laxatives. The burn is located where the child’s skin had prolonged exposure to stool

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action, and the penetration of the chemical (Palao et al. 2010). Parental drug abuse may also contribute to the prevalence of chemical burns. There have been reports of children ingesting chemicals and sustaining oropharyngeal burns from chemicals used in the production of illicit drugs such as methamphetamine (Farst et al. 2007). There have been reports of laxative-induced dermatitis (see Photo 13) causing blistering to the buttocks which were confused with an immersion thermal burn; these burns were contained within the diaper, spared the creases, and appeared “diamond shaped” (Leventhal et al. 2001). Laxative-induced dermatitis is thought to be due to a higher concentration of digestive enzymes in the stool secondary to a quicker gut transit time (Leventhal et al. 2001).

Electrical Burns Electrical burns are described as either high voltage (more than 1000 V) or low voltage (less than 1000 V). Low-voltage burns are typically caused by contact with household current and are more common in younger children (Celik et al. 2004). High-voltage burns can result from contact with power lines and are more often seen in adolescents (Celik et al. 2004). Electrical burn injuries can range from a local tissue injury to multisystem life-threatening injury. Children who have sustained electrical burns are at risk of deeper tissue injury because of the electrical conduction through the body’s tissues. They may have cardiac, kidney or liver injuries, muscle breakdown, or even fractures – which can be seen due to muscle contracture (Zubair and Besner 1997). Generally, high-voltage burns are associated with a higher mortality. Children who sustain high-voltage burns are frequently admitted to the hospital to monitor for signs of cardiac injury and arrhythmias and typically have a longer inpatient stay because of this (Arasli Yilmaz et al. 2015). A common history given when children sustain low-voltage burns involves a child playing with or chewing on exposed wires or inserting objects into outlets. An injury unique to chewing/biting on electrical cords is a burn at the oral commissure which can have poor cosmetic and functional outcomes. During healing of burns of the oral commissure, children are at risk of significant bleeding from the labial artery when the eschar covering the wound sloughs off; this has been estimated to occur in up to 25% of these cases (Hoffman and Trigger 2017). Although most electrical burns are sustained accidentally, there should be consideration given to whether a lack of supervision or an unsafe living environment contributed to the injury.

Friction Burns Any type of friction event can also cause a burn. The mechanism involved includes a physical deformation of the skin and thermal energy created from the friction. These can be caused by falling onto pavement or gravel and can sometimes be referred to as “road rash.” Friction injuries in children have previously been described to have occurred after contact with objects like slides, ropes, or treadmills (Johnson et al. 2017).

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Photo 14 Friction burn caused by a ligature around a child’s neck

Photo 15 Child with frostbite after getting out of the home in January

Most friction burns are minor, but, depending on the mechanism involved, some can be full-thickness injuries necessitating surgical management (Agrawal et al. 2008) (Photo 14).

Cold Injury Cold panniculitis, also known as popsicle panniculitis, is inflammation of the subcutaneous fat caused by cold exposure. It can be seen in children who are in a cold environment or when eating cold objects like popsicles and can be confused

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with skin infection or burn. Frostbite is the acute freezing of tissues after exposure to cold temperatures (Murphy et al. 2000). It is a spectrum of injuries and can result in irreversible tissue destruction (Murphy et al. 2000). These injuries can begin at temperatures less than 6  C (Boles et al. 2018). Supervisory neglect can also contribute to cold injury in cases of children who suffer frostbite after getting out of their homes during cold weather. One study which analyzed children treated for frostbite found that lack of supervision was a major risk factor in pediatric frostbite (Boles et al. 2018) (Photo 15).

Medical Child Abuse There have also been reports of burns as medical child abuse. One case report discussed a 15-month-old child with recurrent scald-like injuries who was previously diagnosed with epidermolysis bullosa but was eventually thought to have been a victim of inflicted burns caused by her mother (Sirka et al. 2018). In the case of two siblings who were brought in to medical care multiple times for oral erosions, it was later discovered that they were being given a cleaning product containing sodium hydroxide (Tamay et al. 2007).

Scene Investigation A scene investigation should be performed in all cases when a burn is suspected to have been intentional or due to neglect or lack of supervision. Members of the multidisciplinary team, typically child protective services and law enforcement, should investigate the area where the injury took place. There are evidence worksheets available to aid in the evaluation like that seen in Fig. 3. The hot water running temperature should be measured at multiple time intervals after the water is turned on, using a thermometer (Knox and Starling 2010). The peak temperature should also be checked in addition to the time it takes to reach peak temperature (Knox and Starling 2010). The standing hot water temperature at the incident location should also be measured at multiple time intervals. Measurements should also be obtained at the incident location including the depth, height from the floor, and distance to faucet handles (Peltier et al. 1997). The temperature of the hot water heater should also be recorded, as well as the location of the hot water heater in the home and whether or not the family has access to the hot water heater in order to change the setting. Scene investigations can also be helpful to evaluate the child’s living situation and identify any dangerous or unsanitary conditions. Also, in the cases of contact burns, the object used to inflict the injury can sometimes be found (Knox and Starling 2010). The information gathered at the scene investigation and the proposed mechanism of injury should be evaluated in the context of the child’s developmental capabilities (Purdue et al. 1988). Studies have been performed previously to evaluate the length of time to cause a burn on human skin at different temperatures. One study found that a burn could be

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Fig. 3 Evidence worksheet for hot water burns (From Knox, Barbara www.wichildabusenetwork.org)

sustained at 52  C (~125  F) with a 2- minute exposure, and that with each degree Celsius rise in surface temperature the time required to burn was reduced by about half (Moritz and Henriques 1947). This is depicted in Fig. 4. Data from studies like

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Fig. 4 Duration of exposure to hot water to cause full-thickness epidermal burns of adult skin at various water temperatures (Katcher 1981)

this have been used to support recommendations that home water heaters should be set between 120  F and 125  F to decrease scald injuries. Another study found that during a random neighborhood survey, about 80% of homes tested had bathtub water temperatures of 130  F or greater (Feldman et al. 1998). This information emphasizes the importance of scene investigations.

Burn Mimics Several dermatologic conditions can be mistaken for burns including infections, dermatitis, or cultural practices. Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are adverse reactions to medications or sometimes an infection which cause the skin and mucous membranes are involved (Schneider and Cohen 2017). The skin can appear red, blisters and vesicles can form, and the skin can begin to slough off. Both SJS and TEN can resemble a scald burn. Infections caused by

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Photo 16 Decubitus ulcer mimicking a burn

Photo 17 Staphylococcal diaper dermatitis thought initially to be a burn

Staphylococcus aureus can also burn mimics as well (see Photos 16 and 17). Specifically, staphylococcal scalded skin syndrome (SSSS) and bullous impetigo have both toxin-mediated S. aureus infections that have been described as being mistaken for burns. In one case review, two children were admitted to a hospital with concerns for a cigarette burn and a scald injury. Only when they continued to develop new lesions in the hospital where they were correctly diagnosed with SSSS (Porzionato and Aprile 2007). There are other wounds which have been

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Photo 18 The same rash depicted in Photo 16 after 24 hours on antibiotics

described as burn mimics as well. In one case report of an adult patient, a decubitus ulcer (like that seen in Photo 18) of the hand was mistaken for a burn (Rudolph 1983). Phytophotodermatitis is a phototoxic reaction caused by skin contact with psoralens, a plant substance, and exposure to UV light (Mehta and Statham 2007). It is most commonly associated with citrus juice exposure. Children with phytophotodermatitis have skin redness and blistering that can appear in whatever pattern the juice/substance had contact with the skin, and can be confused with contact or splash burns. Cultural practices may sometimes be mistaken for burns as well. One such practice, called moxibustion, is a remedy used in Asian cultures which involves rolling the moxa herb into a ball, placing it on the body and igniting it (Hansen 1998). This leads to the appearance of multiple small burns. Another practice involves creating small burns over a problematic body part resulting in what is called a “Maqua”, which may be seen in Arabic cultural remedies (Hansen 1998). There have also been reports of burns caused by the application of garlic as a remedy for a multitude of ailments. One such report involved a 7 month old child who sustained second degree burns to her feet after they were wrapped with garlic cloves (Zazzera 2017).

Key Points 1. Burns are a common childhood injury and are a manifestation of nonaccidental trauma. 2. A thorough history is important in determining whether a burn is accidental or inflicted. 3. Additional medical evaluation to assess for occult injury should be considered in cases of inflicted burns.

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4. There are multiple types of burns including thermal burns, radiant burns, chemical burns, electrical burns, friction burns, and cold injury. 5. A scene investigation should be performed in cases when abuse is considered. 6. Dermatologic conditions including infections and dermatitis can be confused for burns.

Summary and Conclusion Abusive burns can lead to significant morbidity and mortality. There are multiple different categories of burns, all of which can be caused both by accidents and inflicted trauma. Certain historical aspects and burn characteristics can aid in differentiating an accidental burn from an abusive burn. Evaluation for occult injury should always be performed in children who are suspected to have sustained an abusive burn. There are many burn mimics that can be confused with inflicted burns. The accurate diagnosis of abusive burns is imperative to the protection of these children and others in their environment and for the prevention of further abusive injuries or death.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Approach to Clinical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Documentation of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Injury Interpretation and Diagnostic Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age and Developmental Ability of the Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Injury Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shape/Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Number of Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Impact of Medical Conditions Affecting Bruising . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Children with Medical Illnesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Children with Bleeding Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Children with Motor Disability: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dating of Bruises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. R. McLaughlin · L. C. Stymiest (*) · A. E. Ornstein Department of Pediatrics, IWK Health Centre, Halifax, NS, Canada Dalhousie University, Halifax, NS, Canada e-mail: [email protected]; [email protected]; [email protected]; [email protected] M. G. K. Ward Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_250

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Laboratory and Radiologic Testing in the Evaluation of Bruising in Suspected Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

It is critical that health care providers have an organized, evidence-informed approach to the evaluation of bruising in children of all ages. Bruises are a common finding in healthy active children and are also the most common finding in child physical abuse. Bruising may be the first detectable injury from maltreatment and is often the only outward sign when other (occult) injuries are present, especially in young infants. Medical evaluation of bruising is essential for the timely recognition of possible maltreatment and also the potential recognition of an underlying medical problem. Lack of appreciation of the significance of bruising could lead to failure to provide protective services, to detect occult injury, and to provide treatment. This chapter will address the clinical assessment of bruises in the context of possible child physical abuse. Evidence will be reviewed, and clinical guidance provided in the following format.

Keywords

Bruising · Bruise · Petechiae · Contusion · Cutaneous injury · Physical abuse · Child maltreatment · Bleeding disorder

Introduction Child maltreatment is a common problem worldwide and is considered to be a significant public health issue (Tarantola 2018; United Nations 2006). In many countries, it is estimated that one quarter to one third of people suffer some form of maltreatment in childhood (United Nations 2006). Children of all ages are at risk for maltreatment, with very young children being at greatest risk for the most serious outcomes from physical abuse including death and long-term impairment (Children’s Bureau 2017; Public Health Agency Canada 2010). Bruising is a common finding in healthy children and is also the most common finding in childhood physical abuse (Public Health Agency of Canada 2010; Maguire et al. 2005a). Bruises resulting from trauma may be seen on active children as a result of their own developmentally normal activities (e.g., bumps and falls), self-harm behaviors, medical procedures, medical conditions, or during the newborn period in relation to the birthing process. Bruising may be the only outward sign of maltreatment in a child who has other injuries (e.g., fractures or head injury), especially in young infants (Harper et al. 2014). Some children may

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initially present with isolated bruising due to maltreatment, and then suffer additional injuries over time if no preventive/protective measures are implemented. These additional injuries may increase in severity over time and expose the child to the risk of severe harm, including the risk of death (Pierce et al. 2009; Sheets et al. 2013). Given bruises are common and may be present with or without maltreatment, health care providers need an approach to identifying bruises that are unusual and/or potentially concerning for maltreatment. Although bruises will generally heal without any medical consequences, recognizing the significance of bruising and identifying bruises that are concerning for physical abuse may lead to recognizing and/or to preventing harm to a child or youth (Harper et al. 2014; Pierce et al. 2009; Sheets et al. 2013). Having an organized approach to this assessment also helps to minimize the possibility of overidentification of physical abuse when bruises represent nothing more than the result of normal active childhood play. This chapter will discuss a clinical approach to the medical assessment, management, and documentation of skin bruising in children.

Pathophysiology The human skin has a multitude of functions and provides the body with protection from external forces such as trauma, infection, and extremes in temperature. The skin is one of the body’s largest and most complex organs composed of multiple layers made of a variety of cell types and supplied by blood vessels and nerves. The skin varies in thickness across different body surfaces (Harris and Flaherty 2011) and is composed of two main layers, the epidermis (outer layer) and the dermis (inner layer). The epidermis is a thin, compact layer which serves as a barrier against the environment. The dermis is thicker and contains collagen and elastin fibers to provide structural integrity of the skin. Nerves and small blood vessels called capillaries course through the dermis. Beneath the dermis is a subcutaneous fat tissue layer. Many blood vessels are found in this layer. Most bruises visible externally occur from bleeding of vessels in this fatty layer. Under normal circumstances, blood circulates through the body within blood vessels, which is called the intravascular space. The term “bruise” refers to a collection of blood that has leaked from intravascular space into the extravascular space and is visible beneath the skin. Leakage occurs when the blood vessel wall has been damaged. As the leaked blood is broken down and reabsorbed, the bruise will change color and shape, fade, and eventually disappear. Many factors affect both the appearance and disappearance of a bruise including the manner in which it was caused, the depth of injury, the pigmentation of the overlying skin, and biological factors related to the tissues, vessels, and blood. (Feldman 1992; Harris and Flaherty 2011; Maguire et al. 2005b; Sugar et al. 1999) Bruises may also be referred to as “hematomas,” a term sometimes used to refer to an area of blood under the skin associated with palpable swelling. The

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smallest form of a bruise is referred to as a “petechia.” Petechiae are tiny dot-like marks that represent bleeding from capillaries, which are small blood vessels near the surface of the skin. Petechiae can occur individually or in clusters (Harris and Flaherty 2011).

Approach to Clinical Assessment Clinicians will undoubtedly note the presence of bruising in mobile children during routine care and in assessing unrelated medical complaints. In most cases, these bruises will not raise concern for child maltreatment, but on occasion, bruises seen in this context may be suggestive of maltreatment. Sometimes, clinicians may be specifically asked to assess bruises for the purpose of determining whether they have been caused by maltreatment. In all cases, it is important that clinicians use a trauma-informed approach to the child and family because any of these individuals may have experienced or been exposed to prior traumatic events.

History A thorough history is essential to understanding the cause of bruising. As with other medical findings, bruises can be caused in a variety of ways and, therefore, a differential diagnosis should be considered. Bruises can result from trauma (i.e., impact, compression, penetration, or other forces applied to the skin resulting in injury) or as a result of certain medical conditions. In some cases, bruises may be the result of trauma in a child who also has an underlying medical condition. The purpose of the history is to collect information in sufficient detail to assess whether there may be a medical condition predisposing or contributing to bruising, a traumatic explanation, or the presence of both trauma and an underlying medical condition. The history should include details about how the bruise was sustained (if known). Focus should be given to the bruising onset and progression, associated symptoms, and presence of other injuries. If a traumatic event is described to have occurred (e. g., fall), details should be sought, including characteristics of surfaces or objects of contact, height of fall, body position before and during the fall, or other descriptors of the event. A sufficiently detailed history should be taken regarding any new symptoms (e.g., fever, upper respiratory tract infection, weight loss, etc.) or signs of medical conditions predisposing to bruising. In order to provide context to how bruising was sustained, a thorough understanding of a child’s developmental stage and progress is critical. A child’s mobility is one of the best predictors of their likelihood to have bruising (Carpenter 1999; Kemp et al. 2015; Maguire et al. 2005a). Attention should be given to the child’s gross motor abilities. An important adage to recall is “those who

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don’t cruise rarely bruise (Sugar et al. 1999).” As such, abuse must be considered in all cases of nonmobile infants with unexplained bruising. In mobile children, their motor abilities (e.g., roll, sit, pull-to-stand, cruise along furniture, walk, run, or jump) should be confirmed. In this way, clinicians can consider whether the injury mechanism is compatible with the developmental abilities of the child. The type of injury mechanism can also be compared to the injuries seen. Relatively minor injuries can precede more severe injuries from physical abuse in young children. These injuries are known as “sentinel injuries.” This term highlights that, although they are relatively minor, these injuries may signal a risk to the child (Feldman et al. 2020; Harper et al. 2014; Lindberg et al. 2015; McIntosh et al. 2007; Petska and Sheets 2014; Pierce et al. 2009; Sheets et al. 2013). The history should include documentation of any past sentinel injury such as bruising or bleeding from the nose or mouth (nasal or intraoral injury), any bruise in nonambulatory children, or other bleeding in young children. The past medical history should also include injuries that required medical attention (e.g., sutures, casting, splinting) as well as specific questions regarding prior symptoms of fractures, burns, or head injuries. A general medical history should be taken to document known medical conditions and previous or recent medication use such as aspirin and anticoagulants that may affect bruising tendency. A family history of bruising or bleeding and diagnosed predisposing conditions should be elicited. It is important to inquire specifically about the following in the patient and their family: • Previous bleeding, bruising, or injury • Response to bleeding challenges (surgeries, dental extractions, lacerations, and other trauma) • Known medical illnesses or bleeding disorders that predispose to bleeding or bruising • History of mucocutaneous bleeding suggestive of a platelet abnormality (e.g., gingival bleeding or epistaxis) • History of bleeding into deep tissues suggestive of a coagulation factor deficiency (bleeding into joints, soft tissues, gastrointestinal, or genitourinary tracts) or cutaneous bruising with significant induration • Family history of heavy menstrual bleeding, postpartum bleeding, postoperative bleeding, need for blood transfusions • Family history of inherited medical disorders that increase risk for bleeding or bruising (e.g., von Willebrand disease, Hemophilia) • Family history of consanguinity • Family history of connective tissue or other genetic conditions Psychosocial history is another important component of the evaluation of bruising. Identifying challenges and strengths in the lives of the caregivers and child can help the clinician understand and respond better to their needs (Pierce et al. 2014).

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Most cases of substantiated physical abuse with bruises occur in the context of what the caregiver perceives to be “discipline,” with the most common causative “object” being the hand (Public Health Agency of Canada 2010). The assessment of bruises offers an opportunity to have an open discussion with caregivers about challenges they may face with their children’s behavior, healthy discipline practices, and religious, familial, or ethnic practices that guide their parenting. This encounter provides an opportunity to discuss a variety of parenting skills including how to guide children’s behavior without the use of physical force.

Examination All children with bruising in the context of possible physical abuse require a complete physical exam to (a) characterize the extent and nature of bruising, (b) delineate other injuries, and (c) identify signs suggestive of an underlying medical condition. Without a careful and deliberate examination of the skin, visually subtle, but clinically significant bruising may be missed. Children and caregivers who have sustained trauma may require additional time and reassurance in order to engage in the examination. Clinicians should take time to establish rapport, discuss their planned examination, and seek consent from the appropriate decision maker (and assent from the child if they are not the decision maker). First, the child’s vital signs, general appearance, hydration, and growth parameters should be assessed. Every effort should be made to examine all surfaces of the skin. Special attention should be paid to the neck, trunk, buttocks, genitalia, ears, hands, and feet as these areas are rarely bruised accidentally, and bruises in these areas may be due to abuse (Carpenter 1999; Collins et al. 2017; Kemp et al. 2014; Kemp et al. 2015; Labbe & Caouette 2001; Maguire et al. 2005a; Pierce et al. 2010). It may be important to examine the child in multiple positions; for example, a child may appear to have distinctly separate areas of bruising on the arm and trunk when examined with the arm raised, but when examined with the arm resting against the side of body it may become clear that the two bruises are in fact “connected” to one another. The clinician should examine the teeth and the tissues of the mouth and throat for signs of bleeding or trauma. Examination of the frenulae of the upper and lower lips and the tongue (thin bands of tissue attaching lip to gum, and bottom of tongue to floor of mouth) should occur for assessment of injury. Note should be made of the presence and appearance of any subconjunctival hemorrhages. These hemorrhages commonly occur immediately after birth, but may be a sign of trauma if they appear after the first days of life. The abdomen should be examined for tenderness, which might suggest intra-abdominal injury. The size of the liver, spleen, and lymph nodes should be assessed. Attention should be given to any dysmorphic features, evidence of skin laxity, joint hypermobility, or bony deformities as indicators of possible underlying medical illness, genetic condition, or bleeding disorder.

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Documentation of Findings Best practices have emerged for documenting physical exam findings among healthcare practitioners who specialize in assessing children for child maltreatment. The clinician is able to create a pictorial representation of any marks seen on exam by documenting with the use of a body diagram. In addition to bruising, all skin markings including birthmarks, skin eruptions (e.g., eczema), and traumatic lesions, such as cuts or abrasions, should be noted (Fig. 1). The clinician should measure and record the size of bruises and describe the shape, color, and contour (flat, raised, or indurated), along with any notable characteristics, such as a pattern. Whether the area is painful, warm to touch, or swollen should also be noted. If multiple marks are present, the distance between, and distribution of, marks should be recorded. When possible, an individual with expertise should photograph the marks with a measuring tool and color bar appearing in each photo. These photographs should be securely stored in the patient’s health record and only obtained with assent or consent, in accordance with state laws or local regulations. In order to avoid angular distortion of patterned injuries, the photos should be taken at right angles to the plane of injury. It is helpful to take distant photos to locate the injury on the body, as well as close-ups. Photographs should be considered as personal health information within the health care system and centers where the photos are taken and stored. Such photos should have appropriate policies and

Fig. 1 Blank body diagram to be used by health professionals to record findings on skin exam. Versions are available in various views and with proportions typical for various ages. This original sketch by Allison Verge (2019) is used with the kind permission of the creator

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procedures in place. Use of medical photography may be helpful in facilitating peer or external review, as well as facilitating communication with child protection, law enforcement, and/or criminal justice professionals, with appropriate consent. Care should be taken to objectively describe the features when bruising is seen. Only those with adequate expertise to provide an evidence-informed opinion appropriate for this purpose should interpret the significance or cause of the marks (i.e., usually a medical professional with sufficient training or experience in the evaluation of bruising or injuries in children).

Injury Interpretation and Diagnostic Considerations A bruise is a collection of blood that has leaked from a blood vessel and is visible beneath the skin. However, health professionals may observe skin findings that appear to be bruises but are not. When assessing a mark on a child, it is important to consider mimics of bruising such as stretch marks, birth marks, hemangiomas, and staining of the skin from dye or ink. Staining from dyes or inks can often be removed by cleansing with an alcohol wipe or soap and water. The history, location, appearance, and description of how a mark has changed over time may help determine if it is in fact a bruise. After an initial examination, if uncertainty remains about the nature of a mark (i.e., bruise or another skin condition such as congenital melanosis/slate grey nevus) serial examinations may be helpful. For example, a bruise is expected to show changes in color and appearance over days, whereas most birthmarks and hemangiomas will be stable over weeks to months. Bruises may occur in a number of situations including, as a result of the birthing process, from medical interventions, through children’s own actions (usually bumps or falls, but may also be through self-harm), or from the actions of another person. In very rare circumstances bruising may occur through normal handling or care, as a manifestation of a medical condition. In most cases, the examination of bruising cannot, on its own, determine either the exact circumstances around the injury event, nor the intent of the actions of the person who inflicted bruising. The medical literature can be useful, however, in identifying the types of bruises that are usually accidental or caused by children themselves (e.g., “normal childhood bruising”) and those that tend to occur more frequently in situations determined to be abusive. These distinguishing features, which should be considered when examining a child with a bruise, will each be discussed in the following sections. When interpreting bruises in children, a physician should consider: • The age and developmental abilities of the child • The location of the bruising • The shape or pattern of the bruise

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• Number of injuries • Presence of any medical symptoms or signs of conditions • The provided and elicited history of injury

Age and Developmental Ability of the Child Of utmost importance is the understanding that any unexplained bruising in a young, nonmobile infant is unusual and merits assessment (Carpenter 1999; Harper et al. 2014; Pierce et al. 2009, 2016; Sugar et al. 1999). In cases of unexplained bruising in young infants, testing for the possibility of occult injuries and for explanatory medical conditions is recommended. A complete examination may detect additional injuries such as intraoral injury or fractures; however, it is well documented that infants with apparently isolated bruises may have clinically occult injuries detected only by radiological studies such as a head CT, brain MRI, or a skeletal survey (Harper et al. 2014; Lindberg et al. 2015). Most young infants have had few hematologic challenges, and infants with undiagnosed bleeding disorders can present with bruising. Further hematologic tests are routinely recommended for the interpretation of bruising in young infants (Anderst et al. 2013; RCPCH 2006; Ward et al. 2013) (See Table 1). As children age and become mobile, bruises occur more commonly through their own actions. Bruises that occur in this way, sometimes also called “accidental bruises,” are typically small, occurring over bony prominences (Fig. 2) on the front of the body, and without a specific pattern or shape (Maguire et al. 2005a). The cause of minor injuries may not be recalled by the child or caregiver. The etiology of atypical bruises, involving either unusual injury events or greater forces, is more likely to have been noted and to be recalled. When a child’s own action is proposed as a cause of bruising, it should correlate with the nature of bruising seen, such as forehead bruising in the setting a child bumping their head or engaging in head-banging behavior. The mechanism should be something within the child’s developmental abilities. Concern should arise when the expected findings from a mechanism provided do not appear to match the bruising seen, or when no explanation is provided for significant bruising without features characteristic of “accidental” bruising (Fig. 3). Table 1 American Academy of Pediatrics, first-line investigation for evaluation of bruising First-line investigation for evaluation of bruising Complete blood count Partial thromboplastin time (PTT) Prothrombin time (PT) von Willebrand factor (vWF) antigen von Willebrand factor (vWF) activity Factor VIII level Factor IX level

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Fig. 2 Facial bruising over bony prominence. Bruising on the forehead of a toddler with abrasions on the nose and chin, seen after a witnessed fall onto pavement. The forehead has little protective soft tissue and is a commonly injured area when young children fall

Injury Location The location of the bruising becomes significant in the assessment of children once they become mobile and can sustain bruises through their own actions. The shin is the most common site of accidental bruising in mobile children. The reason the shin is so easily bruised in typically active children is twofold; first the shin is a common area to be hit against a surface or object when a child falls or trips, and second there is little subcutaneous tissue over the bony prominences to absorb the force, allowing blood vessels to be easily compressed between the external force and the underlying bone, causing damage to the vessel and leakage of blood beneath the skin. In toddlers, the forehead is another commonly bruised location. Toddlers have frequent falls, resulting in application of force to that area, and like the shin, the forehead has little protective soft tissue (Fig. 2). In contrast to the shin or forehead, locations such as the ears, chest, neck, and back are relatively protected from accidental injury due to their position and/or protective reflexes and are less commonly bruised as a result of routine childhood activity. Though areas such as the buttocks, midarms, and midthighs may come into contact with objects as children move around, bruising in these areas is uncommon due to the presence of significant subcutaneous tissues, which absorb force and cushion the underlying blood vessels.

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Fig. 3 Facial bruising. Facial bruising involving multiple areas of the forehead, under eyes, and cheeks. It is unusual for bruising to occur in soft padded areas, such as the cheeks, from accidental injury and is concerning for possible inflicted trauma without a clear history. The finding of multiple bruises, on multiple planes, is also concerning for possible inflicted injury

In general, bruising on the ears, neck, soft areas of the face, feet, buttocks, genitalia, and torso (including chest, back, and abdomen) is uncommon in the context of children’s normal daily activities (see Figs. 4, 5, and 6). Such injuries should prompt the clinician to carefully consider whether they may be related to child maltreatment (Carpenter 1999; Hibberd et al. 2017; Kemp et al. 2014, 2015; Labbe and Caouette 2001; Maguire et al. 2005a; Maguire and Mann 2013; Pierce et al. 2010; Ward et al. 2013).

Shape/Pattern The shape of bruises may suggest how they occurred. Patterns that have been previously described include those from handprints, loops or belt marks, or other tools. Linear or “Y” shaped bruising may be caused by skin crimping between gripping fingers (Petska et al. 2019). In some cases, a mark may be recognized as “patterned” (Figs. 7 and 8), but it is often difficult for a health professional to determine what specific object has caused the injury, based on appearance alone (Fersini et al. 2017; Maguire et al. 2005a; Ward et al. 2013) (Figs. 7 and 8). The pattern may reflect a positive imprint (markings from the sole of a shoe following impact with that shoe), or a negative imprint (parallel linear lines that reflect spaces between fingers from impact with a hand) (Fersini et al. 2017). If the

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Fig. 4 (a, b, c) Ear bruising in a child. The ear is uncommonly bruised in typical childhood play and accidents. Ear bruising is identified more commonly in abused children than in controls. Detection of ear bruises requires a detailed skin examination as such an area may be missed on a cursory exam, especially in children with long hair

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Fig. 5 Neck bruising. The neck is an uncommon location for bruising from typical childhood play or accidental injury. To identify neck bruising, a detailed skin exam is required, especially in young children whose neck tissue may be more difficult to visualize due to skin folds

Fig. 6 Torso bruising. The torso is an uncommon location for bruising from typical childhood play or accidental injury. Torso bruising is identified more commonly in children who have been abused than in controls

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Fig. 7 Patterned bruise on the upper arm of a child. This bruise shows “C” shaped lines suggestive of the outline of an object. The specific object cannot be identified from the bruise alone. Additional information was available from the child’s interview with child welfare agents and police

body is struck at high velocity, as can be seen with hand slaps or looped cord whippings, the vessels under the object are compressed, pushing blood outward. At the margin of the injuring object, the small capillary blood vessels stretch with the excess blood volume and may pop, causing the injuring object to be outlined by a confluent line of petechiae, which surrounds the pale image of the impacting object. Some abusive bruise patterns are determined by the anatomy of the area injured rather than by the object involved. For example, when the ear is impacted and pressed against the side of the skull, petechial bruising may develop along the rim of the upper helix. Similarly, parallel vertical bruising along the gluteal cleft is seen after application of horizontal force due to the anatomic shape of the buttock with the two convex curves of the buttock cheeks coming together at the cleft (Feldman 1992) (Fig. 9).

Number of Injuries When children are evaluated for possible inflicted injury, a full skin examination is recommended. The framework above applies to the assessment of each identified

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Fig. 8 Cluster of bruises on the upper arm of a child. Bruising seen following a reported bite by another child at a child care center. Both the location (padded protected area) and the patterned shape (arch) of these bruises are atypical for accidental injury

bruise – the age and developmental stage of the child, the location of the bruise, and the shape or pattern of the bruise. Health professionals should consider each identified injury and the totality of the constellation of injuries. Minor accidents are common in active children, and these events may result in bruising. However, such histories may also be fabricated to explain bruises that are in fact the result of physical abuse. Hibberd and colleagues explored injuries in children seen after eight types of accidental events including falls from standing height, falls from less than one meter, falls from 1 to 2 m, hitting an object while falling, falling down stairs, crush injuries, sports injuries, and motor vehicle collisions. They found that most events resulted in a single bruise. No single event resulted in more than five bruises, and even four or five bruises were a rare finding (Hibberd et al. 2017). The total number of bruises seen on a child’s body may be higher in abused children than in nonabused children (Figs. 3 and 6). In a case-controlled study of children admitted to a pediatric intensive care unit because of trauma, the abused children had up to twenty-five bruises (median 6 bruises) while no child with accidental injury had greater than four bruises (median 1.5 bruises) (Pierce et al. 2010).

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Fig. 9 Bruising on the buttocks of a child. In addition to bruising across both buttocks, this child had two vertical lines of darker bruising medially, along the gluteal cleft. This pattern of vertical lines results from the two convex curves of the buttock cheeks coming together at the cleft when a horizontal force is applied

Kemp (2014) also showed a greater number of bruises in children for whom abuse was diagnosed compared to those for whom abuse was excluded. However, the difference in the number of bruises between groups was smaller than in other studies, with considerable overlap – a mean of 2.3 bruises (range 0–12) in the children determined to have been physically abused, and 1.7 bruises (range 0–14) in the children for whom abuse was excluded. Other studies have also shown greater than ten bruises on children who are not suspected victims of inflicted trauma (Kemp et al. 2015; Labbe and Caouette 2001; Sugar et al. 1999). As such, though abused children may have more bruises than nonabused children, it is important to consider other factors such as the age of the child, the location of the bruises, any pattern of the marks, and the history, or histories, of trauma (Fig. 10). Clinicians should recall their professional duty to report and contact local child protection services per their legislated mandate in all cases of bruising with features seen more commonly in child maltreatment, and in any case where there is concern for the child’s safety.

Impact of Medical Conditions Affecting Bruising The medical professional should consider information obtained through history or physical examination that may suggest that the child under evaluation has an underlying medical illness, genetic condition, or bleeding disorder that might impact the

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Fig. 10 Multiple shin bruises. Numerous bruises over the shins seen following witnessed repeated contact of the anterior leg with the pedals of a bicycle while learning to cycle. Though the bruises are numerous and large, they are compatible with the trauma history. Children who are abused may on average have more bruises than nonabused children; however, it is always important to consider other factors such as the age of the child, the location of the bruises, any pattern of the marks, and the history of trauma

likelihood of bruising or the appearance of the skin. This information should be combined with consideration of the child’s age, the location, and the shape of a bruise.

Children with Medical Illnesses Numerous medical conditions have an association with bruising in children including infections (e.g., meningococcemia), some cancers (e.g., leukemia), connective tissues diseases, autoimmune or inflammatory disorders, and nutritional deficiencies (Ward et al. 2013). Additional distinguishing characteristic features in the child or family’s history or other signs that can be detected by thorough physical examination are typically present in these conditions. In the setting of cancers, for example, a history of constitutional symptoms such as weight loss may be elicited, or the presence of enlarged lymph nodes on physical examination. In cases of bruising associated with infection, children or young people usually present with fever and signs of being systemically unwell. In general, unless there are other clinical features present, these conditions can be excluded based on clinical grounds, without extensive screening tests.

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Children with Bleeding Disorders Biological plausibility and clinical experience inform physicians’ opinions that children with disorders of coagulation may bruise with less force than other children. Until recent years, studies on bruising in this population that supported these opinions were limited. Recent reports have described bruising in young children with a variety of bleeding disorders and compared this to unaffected children or control subjects (Collins et al. 2017). Work by Collins compared nonmobile babies without bleeding disorders to those with mild to moderate bleeding disorders and demonstrated that in both groups, there were no bruises identified during 93% of checkups. There was no difference between groups on the number of checkups during which at least one bruise was seen. However, when the babies with bleeding disorders had at least one bruise, they were more likely to have multiple bruises present at that check-up. Babies with severe bleeding disorders were much more likely to have at least one bruise present, and to have a larger number of bruises present. For all ages, children with bleeding disorders tended to have larger bruises and more bruises at a time than controls. Some locations of bruises were rare even in children with bleeding disorders, such as the ears, neck, cheek, eyes, or genitals. Thus, bruising on a nonmobile infant, or bruising at these identified locations should raise concern for abuse, even if a bleeding disorder is suspected or diagnosed. (Collins et al. 2017) Most cases of bleeding disorders will be readily identified based on history and first-line testing (see section on Laboratory and Radiologic Testing in the Evaluation of Bruising in Suspected Maltreatment below). In cases where there is an unusual personal or family history or where initial testing results are inconclusive, consultation with a pediatric hematologist may be helpful. It is important to also remain aware that the presence of a bleeding disorder does not rule out the possibility of abuse.

Children with Motor Disability: Children with motor impairments leading to disability are underrepresented in the general literature on bruising. In studies where bruising has been assessed specifically in this population, there is heterogeneity in the findings. As with children without disability, children with disability sustain more bruises when they are able to walk compared to those who use are unable to ambulate (Newman et al. 2010). In other reports examining children with more severe disability, however, there was no association between degree of mobility and likelihood of bruising (Bennett et al. 2012; Goldberg et al. 2009). Children with severe motor disabilities are more likely to have bruising on their backs, abdomen, pelvis, and feet compared to children without disability (Goldberg et al. 2009). These areas may be less protected than in children without disability and more prone to injury during transfers. Consideration must be given to the use of aids or equipment that may influence the types of injuries observed in this population. Involuntary movement disorders may also influence the frequency of

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bruising in this population (Bennett et al. 2012) and should be reviewed during the medical history. In general, as compared to their peers, children with disability tend to have more bruises on their feet and fewer on their shins. Bruises in certain areas such as the buttocks, cheeks, chin, ears, and neck are uncommonly seen in children with or without disability and should raise concern in both groups of children (Goldberg et al. 2009; Newman et al. 2010). More research is needed to better understand bruising in children with motor disability.

Dating of Bruises It is important to understand that the color of bruising does not reliably or accurately provide an assessment of the age or progression of a bruise for the purposes of assessing the timing of an injury (Bariciak et al. 2003; Maguire et al. 2005b; Maguire and Mann 2013; Schwartz and Ricci 1996). Though bruises cannot be accurately dated by appearance, history may be helpful for determining when a bruise first appeared, or when symptoms of injury first occurred. When caregivers describe a narrow timeframe between when the area of skin was observed uninjured, and when the area was seen again and was bruised, it can be estimated that the bruise likely appeared near the time it was first noted. However, if the area of the bruise had not recently been visualized (i.e., buttock hidden by clothing) it can be difficult to estimate how long the bruise has been present. Because of factors such as volume of blood in a bruise or depth of tissue, bruises may not appear immediately after trauma. Bruises arising from bleeding near the skin surface are expected to develop more rapidly than those that arise from bleeding in deeper tissues. Thus, petechiae at the skin surface may arise almost immediately after injury, while in some cases bruises associated with long bone fractures may take a day or more to appear as the blood tracks along fascial planes to the surface. It should be noted, however, that these general principles do not provide enough scientific certainty to provide an exact age of the injury. A history of a bruise appearing at the site of recent trauma is supportive of that trauma as the cause of the bruise but does not exclude other possible causes. Additionally, the absence of a bruise at the reported site of impact does not exclude that impact occurred.

Laboratory and Radiologic Testing in the Evaluation of Bruising in Suspected Maltreatment Laboratory testing may be considered in some cases to identify medical conditions that predispose a child to bruising. Not all children with bruising require laboratory tests. Testing can be considered in the setting of historical or physical examination findings concerning for a bleeding condition, or in cases of unexplained isolated

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bruising and bleeding. Hematologic laboratory testing is recommended in nonmobile infants with bruising, as they have had fewer hemostatic challenges, which means that the absence of significant past bleeding is less reliable for excluding a bleeding disorder in this population. Laboratory testing guidelines for the evaluation of bruising in cases of suspected child maltreatment have been proposed by the Canadian Pediatric Society, American Academy of Pediatrics, the British Royal College of Paediatrics and Child Health, and others (Anderst et al. 2013; RCPCH 2006; Ward et al. 2013). The majority of first line tests are similar between guidelines. In addition to those listed in Table 1, The Canadian Pediatric Society recommends liver and renal function studies for secondary platelet dysfunction. The British guidelines take a more limited approach to the initial screen, recommending only complete blood count, blood smear, partial thromboplastin time (PTT), prothrombin time (PT), thrombin time (TT), and fibrinogen. No screening panel can exclude all possible bleeding disorders. These first line medical investigations serve to identify the majority of clinically relevant bleeding disorders in the general population. If initial test results are abnormal, or if the personal or family history suggests an increased likelihood of an underlying bleeding disorder, consultation with a pediatric hematologist may be required. It is important to remain aware that the presence of a bleeding disorder does not rule out the possibility of abuse. Medical testing may be helpful not only to identify bleeding tendency, but also to identify any additional injuries that may not be clinically apparent. It is recommended that a skeletal survey be done for all nonmobile infants with unexplained bruising and in toddlers with unexplained bruising suspected to be from physical abuse. In practice, this applies to children under the age of 2 years (Anderst et al. 2013). Head and brain imaging to evaluate for occult intracranial injury should be strongly considered for all infants and toddlers having an assessment for possible physical abuse, and particularly for those under the age of 1 year. Ophthalmologic assessment may also be considered. As children age, the physical examination becomes more reliable at excluding injury, and thus head imaging and x-rays are required over the age of 2 years only when there is a clinical suspicion of an underlying injury or the information available suggests a high risk situation for prior unrecognized injuries (Anderst et al. 2013; Ward et al. 2013).

Key Points • Bruising is common in healthy children but is also the most common physical finding of child abuse. • Typical accidental bruising occurs in mobile children, and the accident history should be compatible with their developmental abilities. • Bruising in nonmobile infants should raise the concern of abuse.

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• Typical accidental injuries are commonly on the front of the body and over bony prominences. • Bruising in soft, padded areas (cheeks, buttocks, and thighs) or in protected areas (ears, neck, and torso) should raise the concern of abuse. • Patterned marks should raise the concern of abuse. • Medical conditions such as bleeding disorders may affect the likelihood of bruising and the appearance of bruising. Medical conditions should be considered when assessing bruising.

Summary and Conclusion Child physical abuse is common across the globe. The most common visible sign of physical abuse is bruising. It is important that clinicians have an evidence-informed, objective approach to the assessment of bruising given that it is also common for children to sustain bruises as a result of normal childhood activities. Bruises may be the only outward sign of maltreatment in a child who has additional occult or “silent” injuries, especially in infants. Given the relationship between bruising and level of mobility, special consideration should always be given to infants with bruising. A sound understanding of the required clinical assessment of bruising, including a systematic approach to identifying features of bruising concerning for maltreatment, is critical to avoid missed opportunities to initiate protective services, to detect occult injury, and to provide treatment.

Cross-References ▶ Abusive Head Trauma: Understanding Head Injury Maltreatment ▶ Corporal Punishment: Finding Effective Interventions ▶ Fractures

References Anderst, J. D., Carpenter, S. L., Abshire, T. C., & The Section on Hematology/Oncology and the Section on Child Abuse and Neglect. (2013). AAP clinical report: Evaluation for bleeding disorders in suspected child abuse. Pediatrics, 131(4), e1314–e1322. Bariciak, E. D., Plint, A. C., Gaboury, I., & Bennett, S. (2003). Dating of bruises in children: An assessment of physician accuracy. Pediatrics, 112(4), 804–807. Bennett, T., Jellinek, D., & Bennett, M. (2012). A pilot study to measure marks in children with cerebral palsy using a novel measurement template. Child: Care, Health and Development, 39(6), 864–868. Carpenter, R. F. (1999). The prevalence and distribution of bruising in babies. Archives of Disease in Childhood, 80(4), 363–366.

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Children’s Bureau. (2017). U.S. Department of Health & Human Services, Administration for Children and Families. Child Maltreatment. Available at https://www.acf.hhs.gov/cb/ research-data-technology/statistics-research/child-maltreatment Collins, P. W., Hamilton, M., Dunstan, F. D., Maguire, S., Nuttal, D. E., Liesner, R., Thomas, A. E., Manley, J., Chalmers, E., Blanchette, V., & Kemp, A. M. (2017). Patterns of bruising in preschool children with inherited blood disorders: A longitudinal study. Archives of Disease in Childhood, 102(2), 1110–1117. https://doi.org/10.1136/archdidchild-2016-310196. Feldman, K. W. (1992). Patterned abusive bruises of the buttocks and the pinnae. Pediatrics, 90, 633636. Feldman, K. W., Tayama, T. M., Strickler, L. E., Johnson, L. A., Kolhatkar, G., DeRidder, C. A., Matthews, D. C., Sidbury, R., & Taylor, J. A. (2020). A prospective study of the causes of bruises in premobile infants. Pediatric Emergency Care, 36(2), e43–e49. Fersini, F., Govi, A., Tsokos, M., Etzold, S., & Tattoli, L. (2017). Examples of tramline bruises in clinical forensic medicine. Forensic Science and Medical Pathology, 13, 508–510. Goldberg, A. P., Tobin, J., Daigneau, J., Griffith, R. T., Reinert, S. E., & Jenny, C. (2009). Bruising frequency and patterns in children with physical disability. Pediatrics, 124(2), 604–609. Harper, N. S., Feldman, K. W., Sugar, N. F., Anderst, J. D., & Lindberg, D. M. (2014). Additional injuries in young infants with concern for abuse and apparently isolated bruises. The Journal of Pediatrics, 165, 383–388. Harris, T. L., & Flaherty, E. G. (2011). Bruises and skin lesions. In C. Jenny (Ed.), Child abuse and neglect: Diagnosis, treatment and evidence (pp. 239–251). St. Louis: Elsevier Saunders. Hibberd, O., Nuttall, D., & Watson, R. E. (2017). Childhood bruising distribution observed from eight mechanisms of unintentional injury. Archives of Disease in Childhood, 102(12), 1103–1109. Kemp, A. M., Maguire, S. A., Nuttall, D., Collins, P., & Dunstan, F. (2014). Bruising in children who are assessed for suspected physical abuse. Archives of Disease in Childhood, 99(2), 108–113. Kemp, A. M., Dunstan, F., Nuttall, D., Hamilton, M., Collins, P., & Maguire, S. (2015). Patterns of bruising in preschool children – A longitudinal study. Archives of Disease in Childhood, 100, 426–431. Labbe, J., & Caouette, G. (2001). Recent skin injuries in normal children. Pediatrics, 108(2), 271–276. Lindberg, D., Beaty, B., Juarez-Colunga, E., Wood, J. N., & Runyan, D. K. (2015). Testing for abuse in children with seninel injuries. Pediatrics, 136(5), 831–838. Maguire, S., & Mann, M. (2013). Systematic reviews of bruising in relation to child abuse – What have we learnt: An overview of review updates. Evidence Based Child Health A Cochrane Review Journal, 8, 255–263. Maguire, S., Mann, M. K., Sibert, J., & Kemp, A. (2005a). Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review. Archives of Disease in Childhood, 90, 182–186. Maguire, S., Mann, M. K., Sibert, J., & Kemp, A. (2005b). Can you age bruises accurately in children? A systematic review. Archives of Disease in Childhood, 90, 187–189. McIntosh, N., Mok, J. Y. Q., & Margerison, A. (2007). Epidemiology of oronasal hemorrhage in the first 2 years of life: Implications for child protection. Pediatrics, 120(5), 1074–1978. Newman, C. J., Holenweg-Gross, C., Vuillerot, C., Jeannet, P. Y., & Roulet-Perex, E. (2010). Recent skin injuries in children with motor disabilities. Archives of Disease in Childhood, 95, 387–390. Petska, H. W., & And Sheets, L. K. (2014). Sentinel injuries: Subtle findings of physical abuse. Pediatric Clinics of North America, 61, 923–935. Petska, H. W., Frasier, L. D., Livingston, N., Moles, R., & Sheets, L. K. (2019). Patterned bruises from abusive squeezing. Pediatric Emergency Care, 00(00), 1–3. Pierce, M. C., Smith, S., & Kaczor, K. (2009). Bruising in infants: Those with a bruise may be abused. Pediatric Emergency Care, 25, 845–847.

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Pierce, M. C., Kaczor, K., Aldridge, S., O’Flynn, J., & Lorenz, D. J. (2010). Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics, 125, 67. Pierce, M. C., Kaczor, K., & Thompson, R. (2014). Bringing back the social history. Pediatric Clinics of North America, 61(5), 889–905. Pierce, M. C., Magana, J. N., Kaczor, K., Lorenz, D. J., Meyers, G., Bennett, B. L., & Kanegaye, J. T. (2016). The prevalence of bruising among infants in pediatric emergency departments. Annals of Emergency Medicine, 67(1), 1–8. Public Health Agency of Canada. (2010). Canadian incidence study of reported child abuse and neglect: Major findings. https://www.phac-aspc.gc.ca/cm-vee/csca-ecve/2008/index-eng.php Royal College of Paediatrics and Child Health. Child protection companion, 2ns ed. London: RCPCH, 2006: 18-21 Schwartz, A. J., & Ricci, L. R. (1996). How accurately can bruises be aged in abused children? Literature review and synthesis. Pediatrics, 97(2), 254–257. Sheets, L. K., Leach, M. E., Koszewski, I. J., Lessmeier, A. M., Nugent, M., & Simpson, P. (2013). Sentinel injuries in infants evaluated for child physical abuse. Pediatrics, 131(4), 701–707. Sugar, N. F., Taylor, J. A., & Feldman, K. W. (1999). Bruises in infants and toddlers: Those who don’t cruise rarely bruise. Archives of Pediatrics & Adolescent Medicine, 153(4), 399–403. Tarantola, D. (2018). Child maltreatment: Daunting and universally prevalent. American Journal of Public Health, 108(9), 1119–1120. United Nations. (2006). World report on violence against children. Geneva: United Nations Publishing Service. Ward, M. G. K., Ornstein, A., Niec, A., & Murray, L. (2013). The aedical assessment of bruising in suspected child maltreatment cases: A clinical perspective, Canadian Paediatric Society Child and Youth Maltreatment Section. Paediatrics & Child Health, 18(8), 433–437.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Delay in Seeking Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Solid Organ Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case Study (Pancreatic Pseudocyst) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hollow Viscus Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Thoracic Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Laboratory Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Imaging Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Inflicted trauma to the abdomen and thorax is an important cause of mortality and the second leading cause of death due to child physical abuse. This chapter explores the epidemiology, clinical presentation, laboratory evaluations, and recommended imaging studies for young children who are suspected to have inflicted thoracoabdominal trauma. Multiple case studies of inflicted abdominal and thoracic trauma are discussed throughout the chapter. The chapter concludes

This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. G. S. Lee (*) · L. D. Frasier Department of Pediatrics, Center for the Protection of Children, Penn State Health Children’s Hospital, Penn State College of Medicine, Hershey, PA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_251

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with a recommendation that a comprehensive assessment of all children suspected of abuse should include a multidisciplinary team approach. This approach may prevent a delay in appropriate medical interventions and provide a more detailed analysis of abusive mechanisms with potential legal protections for the child. Keywords

Abdominal trauma · Child abuse · Physical abuse · Thoracic trauma · Liver injury · Pancreatitis · Rib fractures · Bowel injury · Peritonitis · Hemoperitoneum

Introduction Inflicted abdominal trauma is a significant contributor to mortality from physical abuse. It is the second leading cause of death due to physical abuse (Barnes et al. 2005). The highest rates of abusive abdominal trauma are seen in infants and toddlers (Lane et al. 2012). The interquartile range for age of children with inflicted abdominal trauma in the ULTRA and ExSTRA study cohort was 5–34 months (Lindberg et al. 2013). Compared with children who are accidentally injured, victims of physical abuse tend to be younger (2.5–3.7 years vs. 7.6–10.3 years) and have a higher mortality rate (53% vs. 21%) (Maguire et al. 2013). They are also more likely to have hollow viscus injuries (Carter and Moulton 2016). Due to a caregiver’s delay in seeking care and incomplete or misleading history, abdominal injuries can be difficult to diagnose (Cooper et al. 1988). Abdominal injuries can also be difficult to diagnose as many children may not have obvious external findings or their abdominal trauma may be obscured by other injuries.

Epidemiology The incidence of abusive abdominal trauma was 2.33 cases per million children per year (95% CI 1.43–3.78) in children younger than 5 years old (Barnes et al. 2005). Although experts have considered toddlers to be at highest risk for inflicted abdominal trauma, infants have higher rates of hospitalization. In 2006, rates of inflicted abdominal trauma were 17.7 hospitalizations per million infants less than 1 year old (95% CI 11.7–23.9), while rates were 12.9 per million in children 1–2 years old up to their third birthday (95% CI 9.2–16.6) (Lane et al. 2012). Maguire’s systematic review found no cases of duodenal injury from accidental injuries (Maguire et al. 2013). This systemic review of abusive visceral injuries in childhood demonstrated that every organ in the body could be injured from abuse. Similarly, Huntimer found no cases of small bowel perforations from stairway falls (Huntimer et al. 2000), and Carter’s case-control study found small bowel injuries in 34.9% of abused children in two pediatric trauma centers (Carter and Moulton 2016). Carter found no duodenal or jejunal injuries in fall casualties. Non-accidental

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trauma was the most common etiology of blunt abdominal trauma for patients younger than 5 years old (26.9%) evaluated at the two pediatric trauma centers (Carter and Moulton 2016). Trokel’s study of blunt abdominal injury in the young pediatric patient evaluated injury causes and patient outcomes in young children with abdominal injuries (972 children less than 4 years old.) The three most common mechanisms of abdominal injury were motor vehicles (61.3%), child abuse (15.8%), and falls (13.6%). Patient outcomes were more severe in the abused children or those with associated central nervous system injury. Child abuse, compared to accidental falls, was independently associated with a sixfold increase in in-hospital mortality (Trokel et al. 2004). Lane found that among children with inflicted abdominal trauma, the organs most commonly injured were the liver (64% of hospitalizations), kidney (19%), stomach/ intestines (12%), spleen (9%), and pancreas (7%) (Lane et al. 2012). Hilmes et al. studied 84 children who were less than 5 years old, with a diagnosis of physical abuse, who underwent CT scans. 35 (41.7%) of the children had abdominal injuries: 15 had liver injuries, 13 had bowel injuries, 4 had mesentery injuries, 6 had spleen injuries, 7 had kidney injuries, 4 had pancreatic injury, and 3 had adrenal gland injuries. Nine of the 35 children (26%) required surgical intervention for bowel, mesenteric, and pancreatic injuries (Hilmes et al. 2011).

Clinical Presentation Clinical signs and symptoms are dependent upon the severity of the injury. Presenting symptoms can be absent, nonspecific, or severe and life-threatening as the injury takes its course or present with a child in severe shock or even death. Vomiting is often a presenting symptom which may be bilious indicating bowel obstruction. Vomiting reflects small bowel injury but can occur in many types of inflicted abdominal trauma. There are frequently no external signs of trauma such as bruising over the abdomen (Cooper et al. 1988; Ledbetter et al. 1988). Abdominal bruising was absent in up to 80% of those with abdominal injuries and co-existent injuries such as fractures, burns, and head injury (Maguire et al. 2013). Another confounding factor upon presentation is that the caregiver may report other family members with similar symptoms. Additionally, because inflicted abdominal trauma can be a factor in infants and children with head trauma, such children may not have an abdominal examination that is indicative of trauma. Therefore, screening for inflicted abdominal trauma is important to obtain in children with serious trauma, even without specific abdominal signs or symptoms (Christian et al. 2015). Other symptoms or clinical presentations of abdominal trauma include diffuse or localized abdominal pain, abdominal distension, fever, nausea, lethargy, thirst, decreased appetite, decreased activity, altered level of consciousness, anemia, elevated liver and/or pancreatic enzymes, and hypovolemic shock due to blood loss or peritonitis.

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History Children who present with inflicted abdominal trauma may not present with a specific history of trauma to the abdominal region. Instead, they may present with a history of symptoms such as vomiting, abdominal pain, fever, crying, and decreased appetite. There may be a history of a recent fall given, as is commonly the case in patients who present with concerns for physical abuse. Patients can present with other signs of injuries such as cutaneous findings, fractures, and head trauma. Depending on the extent of the thoracoabdominal injuries, patients can present with respiratory distress or failure and even in sudden arrest and shock.

Delay in Seeking Care A delay in seeking care for a sick child may or may not assist in determining if a child sustained an inflicted abdominal trauma. Due to the nature of the nonspecific signs and symptoms of injuries within the abdominal cavity or thorax, patients may not seek medical attention for several days. It takes time for bowel injuries to become symptomatic and for symptoms to develop depending on the severity and the degree of compression on the surrounding area. By the time of presentation, the abdominal injury may have improved significantly. The presentation of young children with abdominal trauma was studied in order to determine whether a delay in seeking care differentiated abusive from accidental abdominal injury (Wood et al. 2005). The authors compared abdominal injuries caused by high-velocity accidental, low-velocity accidental, and inflicted injury. High-velocity accidental injuries were defined as a motor vehicle crash or fall from greater than 10 ft. Low-velocity accidental injuries were defined as a household trauma, bicycle crash, or a fall from less than 10 ft. Solid organ injuries (e.g., injuries to the liver, spleen, or kidney) were most common in all the age groups. Abused children were significantly more likely to have suffered a hollow organ injury. Presentation for care occurred within 12 h for 100% of the high-velocity accidental group, but only 65% of the low-velocity accidental group, and 46% of the abuse group. Presentation to care at greater than 12 h was neither specific nor highly predictive of abuse. Some children with low-velocity accidental injuries presented for care late despite developing symptoms shortly after their injury occurred (Wood et al. 2005).

Solid Organ Injuries The most common mechanism for any injury to the abdomen is focal blunt force trauma. Typical blunt force trauma injuries include motor vehicle collisions, bicycle handlebar injuries, and inflicted injury from punching, kicking, or stomping on the abdomen. The most common solid organ injuries in inflicted abdominal trauma are

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liver lacerations, with the left lobe most commonly involved due to the anatomic position, and soft abdominal muscles in young infants and toddlers. Liver injuries can range from a minor contusion that may be asymptomatic and suspected only by elevated liver transaminases to a massive laceration with hemoperitoneum and lifethreatening hypovolemic shock. Pancreatic injuries are less common, most likely due to the organ’s retroperitoneal position within the abdominal cavity and proximity to the spine. The pancreas is a retroperitoneal organ and is surrounded and covered by the bowel. Its location just over the spine makes it susceptible to compression from a deep blow to the abdomen. Traumatic pancreatitis may present as vomiting, diffuse or localized abdominal pain, vomiting, and shock. Pancreatic injuries include peripancreatic hematomas, pancreatic contusions, lacerations, and transections (Callahan and Knight 2018). A late complication of pancreatic injury is the formation of a pancreatic pseudocyst. When a pancreatic pseudocyst is identified in a child without another clear etiology, a non-accidental trauma workup is recommended. This includes a comprehensive physical examination, skeletal survey if age appropriate, social evaluation, and consideration of abuse in siblings and young household contacts.

Case Study (Pancreatic Pseudocyst) A 4-year-old boy presented to the emergency department with 2 days of right-sided abdominal pain, fever, and tachycardia. There was no recent history of trauma, and he had a 5 pound weight loss in the 2 weeks prior to presentation. Parents report that he developed vomiting 3 weeks prior to presentation and that the “whole family” had a “stomach bug” with vomiting and diarrhea. Three months prior, there was a history of falling off a bed and fracturing his left elbow. He also had a history of recent burns on his left hand and right foot from a ramen noodle spill. The current episode recurred after 2 weeks of symptom resolution. When he presented to the hospital, he was noted to have swelling of the dorsum of his left hand as well as bruising of his left fifth digit, left wrist, and right foot. His initial lipase was 196 IU/L and continued to increase over a week to >600 IU/L. His AST and ALT were both within normal limits. An abdominal CT was performed which showed a pancreatic pseudocyst which was exerting mass effect on the adjacent organs, most notably the stomach. MRI of his abdomen showed a pancreatic laceration between the tail and the body of the pancreas. A skeletal survey was performed which showed fractures of the third and fourth fingers of the left hand, cortical thickening of the right ulna, healing left humerus fracture, and healing left 7th rib fracture. During his hospital stay, the pancreatic pseudocyst continued to enlarge and 1 l of fluid was drained, and a stent was placed (Fig. 1). Patient remained on TPN for 14 days with a slow advancement of diet. He was then discharged to foster care. Splenic injuries secondary to inflicted abdominal trauma are less frequent than hepatic injuries, likely due to its somewhat protected position in the right upper quadrant. The spectrum of injury to the spleen includes lacerations, hematomas, and

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Fig. 1 CT abdomen with contrast showed a large pancreatic pseudocyst, indicated by the white arrow

Fig. 2 Multiple bruises and abrasions over the spinous processes caused by impact with the tiled floor. Stepmother reported stomping on the child’s abdomen while she was laying supine on a tiled floor

rupture. When abdominal injury is suspected, a CT of the abdomen and pelvis with intravenous contrast is recommended (Sheybani et al. 2014) (Figs. 2 and 3).

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Fig. 3 At laparotomy, in a child who was reportedly stomped on by her stepmother, a full transection of the second portion of the jejunum is demonstrated by the forceps

Renal injuries secondary to inflicted abdominal trauma include hematomas, contusions, adrenal hemorrhage, and renal vascular injuries. The presence of gross hematuria with a urinalysis may indicate renal injury in the context of abdominal trauma in children. CT imaging of the abdomen and pelvis with intravenous contrast is the imaging method of choice to assess for renal injury (Sheybani et al. 2014).

Hollow Viscus Injuries Hollow viscus injury is relatively more common in inflicted abdominal trauma than in accidental trauma (Maguire et al. 2013), as previously noted. Injuries range from mild contusions or intramural hematomas, most commonly of the duodenum, to complete transections or vascular avulsions. The duodenum is particularly susceptible due to its fixation by and location over the spine, allowing for compression or laceration of the bowel. Injuries to the duodenum can range from a small focal to a large obstructing hematoma, to a perforation, to a complete transection of the hollow viscus. Any section of the alimentary canal has been reported to have injury from abuse (Maguire et al. 2013). In contrast to small bowel injuries, gastric injury is rare, but there have been causes of gastric rupture or gastric hematoma. Isolated cases of gastric rupture have been reported in abused children (Schechner and Ehrlich 1974; Tollner et al. 1984) (Fig. 4).

Thoracic Trauma Thoracic trauma includes cardiac injury, pulmonary injuries, and aortic injuries. Abusive injuries that involve the heart are rare and include direct cardiac trauma, dysrhythmias, commotio cordis, pericardial effusions, myocardial contusions, and

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Fig. 4 CT of the abdomen was performed in this child because of elevated liver transaminases. The black arrow indicates a liver laceration

Fig. 5 At autopsy of a victim of child physical abuse, the abdominal cavity is filled with blood, and the mesenteric root is completely disrupted which resulted in acute fatal exsanguination

cardiac aneurysms and rupture. Abusive pulmonary injuries include pulmonary contusions, pulmonary edema, pneumothorax, and pneumomediastinum (Fig. 5). Rib fractures are strongly associated with physical abuse. In isolation, rib fractures don’t cause mortality, but they are seen in children who die from trauma. Using the Kids’ Inpatient Database, Leventhal found that 69% of rib fractures found in infants less than 12 month old were from abuse (Leventhal et al. 2008). Bulloch’s

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study showed that 82% of identified rib fractures were caused by child abuse (Bulloch et al. 2000). They are usually due to forceful squeezing of the chest, are often multiple, and can be unilateral or bilateral. Oblique views of the ribs and follow-up skeletal surveys performed 2 weeks after an initial skeletal survey can help increase the identification of inflicted rib fractures (Christian et al. 2015). There have been case reports of lower thoracic and abdominal aortic pseudoaneurysms after blunt abdominal trauma (Pisters et al. 1993). Another published case report discussed a toddler with aortic transections after abusive injury. A 16-monthold female was brought in by her babysitter, who had reportedly found her choking and cyanotic. Her lower extremities were flaccid and pulseless. Child abuse was immediately suspected. She received an emergency exploratory laparotomy which revealed a large retroperitoneal hematoma, a lacerated inferior vena cava, and complete transection of the abdominal aorta below the origin of the inferior mesenteric artery (Fox et al. 1996). Blunt force cardiac injury may accompany abdominal trauma, chest bruising, or rib fractures or occur in isolation. Commotio cordis is a phenomenon in which direct impact to the precordium results in an unstable cardiac rhythm. This abnormal heart rhythm can be fatal and can occur with even relatively minor trauma and can leave little or no evidence at autopsy. Case reports of abusive commotio cordis have been published about young children and infants. One case described a 7-week-old male who was home alone with his father, when he began spitting up blood during a diaper change. The child was found to be in asystole and without respirations. He was pronounced dead about 3 h after the father called 911. Autopsy showed significant pulmonary hemorrhage and four rib fractures. No etiology was identified for the pulmonary hemorrhage, and the rib fractures were thought to be from cardiopulmonary resuscitation. The manner of death was certified as natural (Baker et al. 2003). A year later, the parents of the deceased child adopted a newborn girl. At 3 months old, she was diagnosed with a femur fracture. At 4 months old, she was diagnosed with multiple healing rib fractures and an occipital skull fracture. When questioned about both his children’s injuries, father admitted that he had used both of his hands to squeeze his daughter and heard her ribs break. He admitted that on the day his son died a year previously, he had become “so frustrated that I suddenly snapped and. . . hit him with my fist on the center of his chest. I hit him with the little finger side of my fist . . . [he] stopped breathing.” After this confession, the deceased child’s body was exhumed. At exhumation, child was found to have 52 healing rib fractures in different stages, multiple subcutaneous back injuries, and a distal femur metaphyseal fracture. No chest wall contusions were found (Baker et al. 2003). Since signs and symptoms of cardiac insult are often nonspecific and may be missed, evaluation with serum cardiac troponin I may be considered in a patient with abdominal and chest injury. In 2011, Bennett reported a 10 patient case series of children from 2 months to 4 years old who had troponin testing with evidence of chest injury (history of blunt trauma to the chest, bruising or abrasions to the chest, or fractures of the ribs, sternum, or clavicles) (Bennett et al. 2011). Cardiac troponin I level was elevated in 7 (70%) of the 10 patients with levels between 2 and 50 times

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the upper limit of normal. This report showed that in cases of thoracic non-accidental trauma, there was elevation of cardiac troponin I levels which suggests sufficient chest trauma to result in heart injury, independent of the presence of cardiac decompensation or shock from other causes (Bennett et al. 2011). In 2015, Bennett reported a prospective study of two groups of children less than 2 years old who presented with non-accidental abdominal, thoracic, or intracranial injuries and similar-aged uninjured children. His study found that troponin I was elevated in 38% of injured children compared with 17% of uninjured children. He concluded that troponin I is more often elevated in children with suspected nonaccidental trauma than uninjured children (Bennett et al. 2015). Chylothorax can also result from a shearing force on the thoracic lymph vessels similar to that exerted in blunt chest trauma. This results in the accumulation of chyle in the pleural space. Chyle is fluid that is rich in triglycerides and chylomicrons. Chylothorax has been reported in cases of physical child abuse. An 11-month-old boy presented with a 1-week history of a cold and 24 h of shortness of breath. He was in obvious distress at presentation, with grunting, coughing, sternal retractions, and nasal flaring. He also had a recent burn over his left scapula. Chest x-ray showed complete opacification of the right lung and mediastinal shift to the left, without evidence of pneumothorax. Thoracentesis yielded creamy white pleural fluid with negative cultures. Pleural fluid analysis revealed significantly high levels of triglycerides. A skeletal survey was done which showed multiple old and new rib fractures, spine fractures, and long bone fractures (Guleserian et al. 1996). In children less than 5 years old with otherwise unexplained chylothorax, we recommend a careful physical examination, social history, and skeletal survey if age appropriate.

Laboratory Evaluation Among 1676 child abuse consultations in a 2009 prospective study, 54 (2%) were found to have abdominal injuries, and AST/ALT >80 IU/L was found to be 77% sensitive and 82% specific for injury. The eligible population were children less than 60 months old who were evaluated by a child protection team. The study concluded that in the assessment of children with potential physical abuse, an ALT or AST greater than 80 IU/L, abdominal distension, bruising, or tenderness warrants investigation for abdominal trauma (Lindberg et al. 2009). An abdominal CT with IV contrast should be performed, as an ALT or AST greater than 80 IU/L showed a sensitivity of 77% (95% CI 65–87%) and specificity of 82% (95% CI 80–84%) for abdominal injury even in the children with no abdominal bruising, tenderness, or distension (Lindberg et al. 2009). The American Academy of Pediatrics guideline recommends that screening laboratory tests, including liver and pancreatic enzyme levels, be obtained in all children who present with serious trauma, even if they do not present with abdominal symptoms. A urinalysis may also help identify renal and urinary tract injuries. Radiographic studies, including contrast-enhancing CT, are helpful in diagnosing intra-abdominal injuries. They are needed when screening laboratory tests suggest

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possible abdominal trauma. Surgical consultation is warranted for children with inflicted abdominal injury (Christian et al. 2015). Evaluation with serum cardiac troponin I may be suggested in a patient with abdominal and chest injury. Screening for blunt force cardiac injuries is important as signs and symptoms of cardiac injury are often nonspecific and may be missed (Bennett et al. 2015).

Imaging Studies Abdominal CT with IV contrast remains the diagnostic test of choice for the evaluation of abdominal injury (Christian et al. 2015). It allows for the identification of solid organ contusions, intramural hematomas, mesenteric hematomas, retroperitoneal hematomas, or late findings such as pancreatic pseudocysts. It also guides non-operative decisions such as length of hospitalization and follow-up. CT is highly sensitive for the detection of solid organ injury. CT findings in the setting of bowel injury can include peritoneal fluid without solid organ injury, bowel wall enhancement and thickening, extraluminal gas, bowel gas discontinuity, and mesenteric stranding (Schonfeld and Lee 2012). The possibility of head trauma needs to be considered in young infants who present with nonspecific symptoms including vomiting, irritability, and lethargy. Head imaging such as cranial CT, MRI, or both must be considered in the evaluation. A skeletal survey for any child less than 2 years old with suspected abuse is the standard tool for helping identify clinically unsuspected fractures that may exist (Christian et al. 2015). Another tool in the evaluation of the pediatric trauma patient is the Focused Assessment with Sonography for Trauma (FAST), a quick and non-invasive bedside ultrasound examination used for the evaluation of blunt abdominal trauma. This ultrasound technique focuses on evaluating the right upper quadrant, left upper quadrant, pelvis, and pericardial windows for free peritoneal fluid. The aim of this study is to find blood in these regions, considered a marker for abdominal injury. However, more than one-third of low-grade pediatric liver or spleen injuries are not associated with free fluid. Given the modest sensitivity for the detection of intraperitoneal free fluid, the FAST exam should not be the screening tool to rule out intra-abdominal injury (Schonfeld and Lee 2012). Holmes found that among hemodynamically stable children treated in a trauma center following blunt abdominal trauma, the use of FAST compared with standard care only did not improve clinical care, length of stay, missed intra-abdominal injuries, or hospital charges (Holmes et al. 2017).

Key Points • Inflicted thoracoabdominal trauma is an important cause of mortality and the second leading cause of death due to child physical abuse. • Highest rates of inflicted abdominal trauma are seen in infants and toddlers.

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• There are frequently no external signs of trauma such as bruising over the abdomen. • Screening laboratory tests, including liver and pancreatic enzyme levels, must be obtained in children who present with serious trauma, even if they do not present with abdominal symptoms. • Abdominal/pelvic CT with IV contrast remains the diagnostic test of choice for the evaluation of abdominal injury.

Summary and Conclusion In order to detect abdominal trauma, abuse must be included in the differential. Inflicted abdominal trauma may present as a “medical” problem, such as gastroenteritis, which may bypass a trauma evaluation. Often injuries (especially slow bleeds or hollow organ tears) are survivable if the diagnosis is made in a timely manner. A delay in seeking medical care is not necessarily specific or indicative of inflicted abdominal trauma especially because a caregiver can be unaware of the injury event. A comprehensive assessment of all children suspected of abuse should include a multidisciplinary team approach. This prevents a delay in appropriate medical interventions and provides a more detailed analysis of abusive mechanisms with potential legal protections for the child.

Cross-References ▶ Abusive Head Trauma: Understanding Head Injury Maltreatment ▶ Bruising in Suspected Child Maltreatment ▶ Child and Youth Fatality Review ▶ Corporal Punishment: Finding Effective Interventions ▶ Corporal Punishment: From Ancient History to Global Progress ▶ Fractures ▶ Overview of Child Maltreatment ▶ Parents Who Physically Abuse: Current Status and Future Directions

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Bennett, B. L., Steele, P., Dixon, C. A., Mahabee-Gittens, E. M., Peebles, J., Hart, K. W., . . . Hirsh, R. (2015). Serum cardiac troponin I in the evaluation of nonaccidental trauma. The Journal of Pediatrics, 167(3), 669.e1–673.e1. https://doi.org/10.1016/j.jpeds.2015.05.042. Bulloch, B., Schubert, C. J., Brophy, P. D., Johnson, N., Reed, M. H., & Shapiro, R. A. (2000). Cause and clinical characteristics of rib fractures in infants. Pediatrics, 105(4), E48. https://doi. org/10.1542/peds.105.4.e48. Callahan, K., & Knight, L. D. (2018). The pancreas in child abuse. Academic Forensic Pathology, 8(2), 219–238. https://doi.org/10.1177/1925362118782047. Carter, K. W., & Moulton, S. L. (2016). Pediatric abdominal injury patterns caused by “falls”: A comparison between nonaccidental and accidental trauma. Journal of Pediatric Surgery, 51(2), 326–328. https://doi.org/10.1016/j.jpedsurg.2015.10.056. Christian, C. W., & Committee on Child Abuse & Neglect. (2015). The evaluation of suspected child physical abuse. Pediatrics, 135(5), e1337–e1354. https://doi.org/10.1542/peds.20150356. Cooper, A., Floyd, T., Barlow, B., Niemirska, M., Ludwig, S., Seidl, T., & . . . et al. (1988). Major blunt abdominal trauma due to child abuse. The Journal of Trauma, 28(10), 1483– 1487. https://doi.org/10.1097/00005373-198810000-00015. Fox, J. T., Huang, Y. C., Barcia, P. J., Beresky, R. E., & Olsen, D. (1996). Blunt abdominal aortic transection in a child: Case report. The Journal of Trauma, 41(6), 1051–1053. https://doi.org/ 10.1097/00005373-199612000-00020. Guleserian, K. J., Gilchrist, B. F., Luks, F. I., Wesselhoeft, C. W., & DeLuca, F. G. (1996). Child abuse as a cause of traumatic chylothorax. Journal of Pediatric Surgery, 31(12), 1696–1697. https://doi.org/10.1016/s0022-3468(96)90054-8. Hilmes, M. A., Hernanz-Schulman, M., Greeley, C. S., Piercey, L. M., Yu, C., & Kan, J. H. (2011). CT identification of abdominal injuries in abused pre-school-age children. Pediatric Radiology, 41(5), 643–651. https://doi.org/10.1007/s00247-010-1899-9. Holmes, J. F., Kelley, K. M., Wootton-Gorges, S. L., Utter, G. H., Abramson, L. P., Rose, J. S., & . . . Kuppermann, N. (2017). Effect of abdominal ultrasound on clinical care, outcomes, and resource use among children with blunt torso trauma: A randomized clinical trial. JAMA, 317(22), 2290–2296. https://doi.org/10.1001/jama.2017.6322. Huntimer, C. M., Muret-Wagstaff, S., & Leland, N. L. (2000). Can falls on stairs result in small intestine perforations? Pediatrics, 106(2 Pt 1), 301–305. https://doi.org/10.1542/ peds.106.2.301. Lane, W. G., Dubowitz, H., Langenberg, P., & Dischinger, P. (2012). Epidemiology of abusive abdominal trauma hospitalizations in United States children. Child Abuse & Neglect, 36(2), 142–148. https://doi.org/10.1016/j.chiabu.2011.09.010. Ledbetter, D. J., Hatch, E. I., Jr., Feldman, K. W., Fligner, C. L., & Tapper, D. (1988). Diagnostic and surgical implications of child abuse. Archives of Surgery, 123(9), 1101–1105. https://doi. org/10.1001/archsurg.1988.01400330077012. Leventhal, J. M., Martin, K. D., & Asnes, A. G. (2008). Incidence of fractures attributable to abuse in young hospitalized children: Results from analysis of a United States database. Pediatrics, 122(3), 599–604. https://doi.org/10.1542/peds.2007-1959. Lindberg, D., Makoroff, K., Harper, N., Laskey, A., Bechtel, K., Deye, K., . . . & Investigators, U. (2009). Utility of hepatic transaminases to recognize abuse in children. Pediatrics, 124(2), 509– 516. https://doi.org/10.1542/peds.2008-2348. Lindberg, D. M., Shapiro, R. A., Blood, E. A., Steiner, R. D., Berger, R. P., & ExSTRA Investigators. (2013). Utility of hepatic transaminases in children with concern for abuse. Pediatrics, 131(2), 268–275. https://doi.org/10.1542/peds.2012-1952. Maguire, S. A., Upadhyaya, M., Evans, A., Mann, M. K., Haroon, M. M., Tempest, V., . . . & Kemp, A. M. (2013). A systematic review of abusive visceral injuries in childhood – Their range and recognition. Child Abuse & Neglect, 37(7), 430–445. https://doi.org/10.1016/j. chiabu.2012.10.009. Pisters, P. W., Heslin, M. J., & Riles, T. S. (1993). Abdominal aortic pseudoaneurysm after blunt trauma. Journal of Vascular Surgery, 18(2), 307–309.

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Schechner, S. A., & Ehrlich, F. E. (1974). Case reports. Gastric perforation and child abuse. The Journal of Trauma, 14(8), 723–725. https://doi.org/10.1097/00005373-197408000-00010. Schonfeld, D., & Lee, L. K. (2012). Blunt abdominal trauma in children. Current Opinion in Pediatrics, 24(3), 314–318. https://doi.org/10.1097/MOP.0b013e328352de97. Sheybani, E. F., Gonzalez-Araiza, G., Kousari, Y. M., Hulett, R. L., & Menias, C. O. (2014). Pediatric nonaccidental abdominal trauma: What the radiologist should know. Radiographics, 34(1), 139–153. https://doi.org/10.1148/rg.341135013. Tollner, U., Henrichs, I., Bittner, R., & Reinhardt, G. (1984). Stomach rupture as a sequela of child abuse. Monatsschrift für Kinderheilkunde, 132(10), 801–802. Trokel, M., DiScala, C., Terrin, N. C., & Sege, R. D. (2004). Blunt abdominal injury in the young pediatric patient: Child abuse and patient outcomes. Child Maltreatment, 9(1), 111–117. https://doi.org/10.1177/1077559503260310. Wood, J., Rubin, D. M., Nance, M. L., & Christian, C. W. (2005). Distinguishing inflicted versus accidental abdominal injuries in young children. The Journal of Trauma, 59(5), 1203–1208. https://doi.org/10.1097/01.ta.0000196437.07011.b1.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definition and Names . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Covert Video Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Case Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Legal Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Munchausen syndrome by proxy is a rare but serious form of child abuse in which the perpetrator uses the medical system to meet her own needs at the expense of her child. By deceiving medical professionals that the child has a problem, unnecessary medical tests and procedures may then ensue creating harm to the child. Boys and girls are equally affected. Over 95% of the perpetrators are mothers with nearly half having some type of medical background. Virtually any medical condition can be lied about or faked, and examples are seen around

This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. R. Alexander (*) · D. Lashley University of Florida – Jacksonville, Jacksonville, FL, USA e-mail: [email protected]fl.edu; [email protected]fl.edu © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_317

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the world. Detection entails an index of suspicion when the supposed condition does not respond to usual interventions, has an unusual course, or “doesn’t make sense.” In some instances, covert video surveillance may be helpful, but procedural and ethical concerns need to be considered. Once diagnosed by an expert team, case management might consist of removal and termination of parental rights. Alternatively, a high structured and rigorous plan of services and therapy could be assembled but would rely on skilled professionals, strict monitoring, and considerable time to ensure the safety of the children. Possible prevention efforts are discussed. Keywords

Munchausen syndrome by proxy · Abuse by pediatric condition falsification · Medical child abuse · Caregiver-fabricated illness in a child · Factitious disorder imposed on another · Child abuse

Munchausen syndrome by proxy is a complicated form of child abuse in which a child is presented for medical care for a condition that is not true. Subsequent medical testing creates physical and emotional abuse for the child via the perpetrator’s deception to medical professionals.

Introduction Munchausen (aka Munchausen’s) syndrome was named after Baron von Munchausen, a literary character based on German nobleman Hieronymus Karl Friedrick Freiherr von Munchausen in the eighteenth century. Baron von Munchausen was depicted as a man who told stories of his adventures of fantasy and improbable narratives. In 1951, Richard Asher described a specific factitious disorder that he described as “a pattern of self-harm, wherein individuals fabricated histories, signs and symptoms of illness” (Asher 1951). When putting a name to this specific syndrome, he recalled the stories of Baron von Munchausen. Here is described a common syndrome which most doctors have seen, but about which little has been written. Like the famous Baron von Munchausen, the persons affected have always travelled widely; and their stories, like those attributed to him, are both dramatic and untruthful. Accordingly the syndrome is respectfully dedicated to the Baron, and named after him.

British Medical Journal, R.A.J. Asher, M.D., F.R.C.P. (Asher 1951)Munchausen syndrome first appeared in the DSM-III edition in 1980, under factitious disorders. It was defined as “the deliberate feigning or exaggeration of injury, impairment, illness, or a psychological condition with the aim of assuming the patient

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role but no other obvious gain.” The factitious disorder class was redefined in the DSM-5 under somatic disorders as “deceptive behavior is evident in the absence of external incentives.” Munchausen syndrome and Munchausen syndrome by proxy are now subclassified within this definition as “factitious disorder imposed on self” and “factitious disorder imposed on another” (American Psychiatric Association 2013). Child abuse recognition mushroomed with the publication of the “The Battered Child Syndrome” (Kempe et al. 1962). Henry Kempe was an American pediatrician, who along with his multi-specialty colleagues, described physical abuse as more common than previously expected. This article laid the foundation for agencies across the country to better protect children who had experienced abuse. It also established a need in the medical community to recognize child abuse as a medical diagnosis. In 1975, Kempe followed with another publication titled “Unusual Manifestations of the Battered Child Syndrome” in which he called for other pediatricians to be aware of unusual ways that children have undergone maltreatment (Kempe 1975). In 1977, 15 years after the monumental article by Kempe and colleagues, the first publication naming Munchausen by proxy was written by a British pediatrician, Sir Roy Meadow. This early publication was comprised of two case studies where a child had symptoms induced by their mother, with one resulting in the death of the child (Meadow 1977). Munchausen by proxy has been formally studied for more than 40 years. However, prior to the Meadow article in 1972, an article was published on crib deaths and apnea. Dr. Alfred Steinschneider described five case studies: two sets of children who were related (Steinschneider 1972). In one family there were two survivors who had three dead siblings. These cases helped to spawn the misguided apnea monitor industry (now superseded by Back to Sleep education). It was not until 23 years later that the mother of these five children confessed to smothering all of them and then making up stories that they had died in their sleep (Firstman and Talan 1997). All of this was based on what was determined to be a Munchausen syndrome by proxy (MSBP) case that resulted in serial murder. While most cases of Munchausen by proxy involve the mother as the perpetrator, fathers have also been noted in the literature (Meadow 1998). The first publication of a father came in 1990 when a 22-year-old father in Iowa brought his infant daughter to the hospital multiple times from 8 days to 4 months of life with reported apnea and seizures (Makar and Squier 1990). It was discovered by nursing staff during the last admission that the father was turning off the cardiorespiratory monitors, suffocating the toddler, and then turning the monitors back on before walking away. The child was removed from the parents and all symptoms ceased. The child did not require further medications or hospitalizations. MSBP has taken some criticism over the years among those in and outside of the medical field, making the need for knowledge sharing and guidelines on the topic even greater. It is now recognized by the medical community as a diagnosis that requires evaluation and treatment.

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Definition and Names MSBP refers to the intentional deception that another person has a medical condition or illness, who then is presented for medical care. With unnecessary tests, blood draws, etc., it is a form of physical abuse and inappropriate medical care. While the latter is technically a form of medical neglect, this is confusing to non-experts who see many medical visits and fail to see that overuse of the medical system can be neglect. The issue is that this is neglect of the child’s actual needs – including to be free of unnecessary medical interventions. In his seminal article, Meadow (1977) coined the term “Munchausen syndrome by proxy” to describe this form of child abuse. Some have suggested that a more accurate spelling would be “Munchhausen” or “Münchhausen” in keeping with the German origins, rather than the Anglican version. A common variation in usage is the term “Munchausen by proxy” syndrome. These are often used interchangeably. Early in the course of understanding of this entity, the term “Polle syndrome” was suggested. Burman and Stevens (1977) apparently were the first to use this term. The real Baron von Munchausen had a second marriage when he was 74 years old to a 17-year-old. A child was born they thought was named “Polle” who died around 1 year of age. Burman and Stevens then used the term “Polle syndrome” when there is a young child in which adult Munchausen behaviors were also seen. This term was used in several publications in the late 1970s and early 1980s (Burman and Stevens 1977; Verity et al. 1979; Ackerman and Strobel 1981; Liston et al. 1983; Clark et al. 1984). As Meadow and Lennert (1984) noted, this was based on an incorrect understanding of the circumstances. Apparently Baron von Munchausen’s second wife was infamous for her affairs before and after marriage. She was ill shortly after the marriage and went to convalescent care. However she spent time dancing and flirting. Nearly 9 months after she was gone, she gave birth to Maria Wilhelmina. Baron von Munchausen contested the paternity. Maria died at 10 months of age of seizures. Apparently the name “Polle” refers to a small nearby town – none of the mother’s children were ever called “Polle.” Because “Polle” is not the name of any child and Maria was likely not the child of Baron von Munchausen, Meadow and Lennert recommended that the term “Polle syndrome” not be used, but Munchausen syndrome by proxy or Munchausen by proxy be used instead. Note that regardless of these usages, what was being described was child abuse. In part because of an encompassing medical emphasis to use descriptive names and to avoid proper names, there has been a continued search for an alternative to MSBP. The American Professional Society on the Abuse of Children (APSAC) in 1998 proposed the term “pediatric condition falsification” (Ayoub et al. 2002). The idea was that presentations sometimes include conditions which are not illnesses (e.g. deafness, developmental disabilities) and that a more expansive term should be used. The American Academy of Pediatrics in 2013 coined the term “caregiver-fabricated illness in a child” (Flaherty et al. 2013). While they considered APSAC’s name, they nevertheless narrowed their

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term to include “illness.” However, using the term “illness” is too restrictive and misses cases. A term such as “caregiver-fabricated pediatric condition” would have been an improvement – including their emphasis on the fabrication by a caregiver. In 2018, APSAC adopted the term “abuse by pediatric condition falsification” to make it clear that the term refers to child abuse (APSAC 2018). Roesler and Jenny (2008) developed the term “medical child abuse.” One intent was to include the role that medical professionals play in unconsciously enabling the deceptions and falsifications. They emphasized that there is a spectrum that includes exaggerations and more minor behaviors before the full-fledged MSBP is committed. Their emphasis was also on an intervention program that could derail the more flagrant behaviors. They argued that the term “Munchausen syndrome by proxy” be dropped altogether – that this is a spectrum of child abuse and not a discrete syndrome as such. However, in using the term “medical child abuse,” they in essence substituted terms albeit theirs was more expansive. In parallel, the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association has increasingly acknowledged this form of abuse. Beginning as an investigational entity in earlier editions, DSM-5 refers to factitious disorder imposed on another (FDIA) which has the following diagnostic features: • Intentional induction or falsification of physical or psychological signs or symptoms in another person. • The individual presents another individual (the victim) to others as ill, impaired, or injured. • The deceptive behavior persists even in the absence of external incentives or rewards. • Another mental disorder does not better explain the behavior. This even may be a single episode. An abuse diagnosis may be assigned as a result of the perpetrator’s behaviors (American Psychiatric Association 2013). The Royal College of Paediatrics and Child Health referred to “Fabricated or induced illness by carers” (2009). Regardless of the different names, the most widely recognized name remains Munchausen syndrome by proxy. It should also be noted that MSBP refers to a pediatric form of child abuse, not a mental health disorder as such. (Technically, MSBP can also refer to elder abuse or animal abuse (Munro and Thrusfield 2001), but most commonly refers to a child victim.) Like other forms of child abuse, the motives of the perpetrator warrant understanding (FDIA) but do not change the harm to the child. The definition of MSBP includes: • Apparent illness or health-related abnormality which the caretaker made up or produced • Presentation of the child for medical treatment

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• Failure of the perpetrator to acknowledge the deception • Exclusion of simple child abuse/neglect and simple homicide Patients who are the victims of MSBP may have an underlying illness/condition or one that used to be present. This may be the jumping off point for the deceptions and presumed attention seeking that the perpetrators apparently desire. Note that MSBP can be considered as abuse by pediatric condition falsification (the abuse) combined with FDIA (the apparent motive). Co-existing motives may also be involved (e.g., soliciting money by portraying a child as being sick).

Epidemiology Munchausen by proxy incidence estimates are hard due to the difficulty in detection, the confusion by medical personal on the topic, and the general notion of child abuse being underreported as a whole. Despite these obstacles there have been studies that have attempted to calculate an incidence rate. The current estimate ranges from 0.5 to 2.0 per 100,000 children under 16 years of age annually (Flaherty et al. 2013; McClure et al. 1996). Cases have been reported in numerous countries. Because of the secretive nature of the abuse and the difficulty in detecting most cases, the actual numbers are likely considerably higher (Bursch et al. 2019). Rosenberg conducted a literature review including all Munchausen by proxy cases from 1966 to 1987, totaling 117 cases (Rosenberg 1987). This review showed a mortality rate of 9% in Munchausen by proxy cases. Others have shown higher mortality rates, including Alexander et al. (1990) showing a mortality rate of 31% when accounting for the index child and their siblings in 5 cases involving 13 children. This same study also showed that mothers who fabricate or induce symptoms in more than one child seem to have worse psychiatric disturbances from the beginning (Alexander et al.1990). In a literature review of 451 cases, Sheridan (2003) found a mortality rate of 6%. Boys and girls are equally likely to be victims (Sheridan 2003). In a literature review of 796 cases, over 95% were committed by mothers (Yates and Bass 2017), but other female caregivers and some fathers (Meadow 1998) are involved. Most were married. About 45% of perpetrators were reported to be healthcare professionals. The most common mental health diagnosis they had was Munchausen syndrome (factitious disorder imposed on self). Personality disorder was seen in 18.6% and depression in 14.2%. Multiple studies have suggested that better detection of Munchausen by proxy comes from tertiary or multidisciplinary centers (Alexander et al. 1990; Ferrara et al. 2013; Sullivan et al. 1991). Part of this phenomenon is likely due to the experts being located at these centers but also the nature of the abuse. Munchausen by proxy is a fabrication or induction of sometimes multiple ailments. When there are multiple specialists needed, these children will end up in tertiary centers that can provide these services.

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Diagnosis Munchausen syndrome was defined in the DSM-III edition in 1980, under factitious disorders. It was defined as “the deliberate feigning or exaggeration of injury, impairment, illness, or a psychological condition with the aim of assuming the patient role but no other obvious gain.” The factitious disorder class was redefined in the DSM-5 under somatic disorders as “deceptive behavior is evident in the absence of external incentives” (American Psychiatric Association 2013). There have been many attempts at characterizing the way Munchausen by proxy is diagnosed despite its myriad presentations. Rosenberg gave a set of guidelines as early as 1987 on how to approach cases of presumed Munchausen by proxy (Rosenberg 1987). The guidelines outlined a 13-step diagnostic plan including: 1. Perform necessary tests to confirm the diagnosis and protect the child immediately. 2. Recognize that nothing is too far-fetched when looking for simulating or producing illness in these cases. 3. Coordinate with the medical staff in the hospital for a safe place to do an evaluation. 4. Interview the child individually if possible. 5. Personally check the mother’s history of witnesses to illness in the child (call the babysitter, relatives, store clerks, etc.). 6. Do a medical record review. 7. Check the family medical history from other medical sources. 8. Document accurately. 9. If presenting the diagnosis to the family, state the diagnosis clear and simple while remaining supportive. 10. Supervise parents while in the hospital room with the child. 11. Psychiatric consultation immediately after informing the parents of the diagnosis. 12. The child should be psychiatrically and psychologically evaluated. 13. Continue on-going communication with the referring doctor; be prepared to put in a lot of time (Rosenberg 1987). Galvin and colleagues stated “once considered in the differential, physicians must search for evidence to include or exclude the diagnosis, while protecting the child from further harm. The use of a multidisciplinary team (including pediatricians and subspecialists, nurses, social workers, the child protection team, and hospital legal counsel) is essential in this process. Specific tests should be performed based on the particular suspicion” (Galvin et al. 2005). The American Professional Society on the Abuse of Children (APSAC) published guidelines in 2018 to make a concise roadmap to identify, report, evaluate, and manage cases of Munchausen by proxy (APSAC 2018). These guidelines state “clinicians should consider the possibility of APCF, CFIC, or MCA in children with highly unusual clinical presentations, when clinical findings are unexpectedly inconsistent

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with the reports of the caregiver, or when a child’s response to standard treatments is surprising. The cornerstone of determining if APCF (abuse by pediatric condition falsification), CFIC (caregiver-fabricated illness in children), or MCA (medical child abuse) is present is identifying unexplained discrepancies, deception, induction, or intentional neglect by the caregiver who created the clinician’s misperceptions regarding the true functional and symptom status of the victim” (APSAC 2018). Certain medical problems are more common with MSBP. The APSAC guidelines summarize previous publications by Roesler and Jenny (2008), Rosenberg (1987), and Sheridan (2003) that show common medical conditions that are falsified or induced. These conditions include the following: allergies, asthma, apnea, gastrointestinal problems, failure to thrive, fevers, infections, seizures, autism, and mitochondrial diseases (APSAC 2018). Numerous others have been reported that are less common. The first step in identifying possible Munchausen by proxy is recognizing a deception. The deception is the key point to diagnosing Munchausen by proxy; figuring out the deception also becomes a very daunting task for medical teams, especially when the medical staff is encountering a caregiver that seems competent and dedicated to their child’s health needs. There are warning signs listed in the APSAC guidelines (APSAC 2018). These warning signs include: 1. Reported symptoms or behaviors that are not congruent with observations. For example, the abuser says the child cannot eat, and yet the child is observed eating without the adverse symptoms reported by the abuser. 2. Discrepancy between the abuser’s reports of the child’s medical history and the medical record. 3. Extensive medical assessments do not identify a medical explanation for the child’s reported problems. 4. Unexplained worsening of symptoms or new symptoms that correlate with abuser’s visitation or shortly thereafter. 5. Laboratory findings that do not make medical sense, are clinically impossible or implausible, or identify chemicals, medications, or contaminants that should not be present. An example is a serum sodium level that is not clinically within reason. 6. Symptoms resolve or improve when the child is separated and well protected from the influence and control of the abuser. 7. Other individuals in the home or the caregiver have or have had unusual or unexplained illnesses or conditions. 8. Animals in the home have unusual or unexplained illnesses or conditions – possibly similar to the child’s presentation (e.g., seizure disorder). 9. Conditions or illnesses significantly improve or disappear in one child and then appear in another child, such as when another child is born and the new child begins to have similar or other unexplained symptoms. 10. Caregiver is reluctant to provide medical records, claims that past records are not available, or refuses to allow medical providers to discuss care with previous medical providers.

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11. The abuser reports that the other parent is not involved, does not want to be involved, and is not reachable. 12. A parent, child, or another family member expresses concern about possible falsification or high healthcare utilization. 13. Observations of clear falsification or induction by the caregiver. This may take the form of false recounting of past medical recommendations, test or exam results, conditions, or diagnoses. When these warning signs are evident, or there are other concerns from the medical staff, it is important to realize the first goal is the safety of the child. There should not be an attempt to “solve” the case, but instead to consult with a child abuse pediatrician or team for assistance. Depending on the level of concern and local protocols, a child abuse report should be considered. These steps achieve two things: (1) the medical team can continue care with the family without raising suspicion and (2) it allows for the medical team to continue on with their own work, while CPS and the child abuse pediatrician work together on obtaining records, keeping the child safe, and coming up with a safe case management plan for the family. Careful documentation is as important as a careful evaluation. Details can be extremely helpful to those conducting a medical or educational record analysis, including information such as who reported that they witnessed the child with symptoms or impaired functioning (and if they saw the symptoms or impaired functioning at the onset), the names of past clinicians who made diagnoses of the child, exactly what education or clinical instruction has been provided to the caregiver and that caregiver’s ability to understand the education or clinical instructions using the teach-back method, episodes of nonadherence or leaving (or threatening to leave) the hospital against medical advice, requests by the caregiver for specific assessments or interventions, episodes of unexplained equipment malfunctions or suspected tampering, and other concerning behaviors. The key involvement for a medical provider is documentation. When it is believed that there is a child who has become a victim of MSBP, the diagnosis commonly comes from the medical records. Conducting a thorough medical record review allows for pattern recognition and assessing for falsified or true medical conditions.

Examples MSBP can take innumerable forms. These examples are presented to give some illustrations of the different ways MSBP might manifest. 1. A 3-year-old girl was brought to the emergency room by her mother who said that the girl had a 2-min seizure 15 min ago. Her description of the seizure did not sound accurate to the ER staff and they found the mother had been to the ER before with doubt about a seizure. A child abuse report was made and it was discovered that the mother had been diagnosed with pseudo-seizures

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(fake seizures). Investigators further discovered that there were two dogs in the home – both on medication for seizures. The child and dogs were removed. 2. A 2-year-old child had recurrent infections leading to sepsis. Numerous hospitalizations included multiple bouts of sepsis. A central line was placed for ease of medication administration. The laboratory reported that on the most recent hospitalization they grew three pathogens when there almost always is only one and that the germs were alien to what humans would have and should have been cleared from the bloodstream quickly. Further investigation showed that they were consistent with germs that might be found in a pond or the flower vase in the room. Upon separation from the mother, there were no more recurrences of infection. 3. A 5-year-old girl had 67 hospitalizations for immune deficiency problems and infections. Although she had testing showing some immune problems, the results varied somewhat over time. During the last hospitalization, the mother was discovered manipulating an IV line. It was found that the mother was injecting feces under the child’s skin. Upon the mother’s removal, the testing was eventually normal. Some of the ways children present are based on lies alone. Reporting that their child has cancer or cystic fibrosis, describing intractable vomiting (perhaps leading to a gastrostomy tube placement), or recurrent pain may only be examples of verbal deception and not necessarily involving tampering of tests or assault of a child. A particularly poignant example detailed an 8-year history of abuse beginning at 2 years of age (Bryk and Siegel 1997). The girl had an injury to her right ankle and was seen by an orthopedic surgeon. Over the next 4 months, swelling persisted. A bone biopsy was done which revealed no underlying cause. There were 28 hospitalizations, 24 surgeries, multiple blood transfusions, numerous radiographs, grafts, and other procedures. The initial diagnosis was cellulitis but eventually included osteomyelitis. Response to antibiotics was poor. At one point amputation of the right leg was considered. Problems developed with the left and right arm. Multiple skin grafts ensued. What was not known to the physicians was that the mother caused the ankle injury by repeated blows with a hammer. This continued for years. The mother (a nurse) would open up incisions and contaminate the wounds with potting soil and coffee grounds. The mother put boiling water in an incision in the right arm. One afternoon the girl stood up to the mother and said she was going to tell her teacher and doctor. The abuse stopped. However, as an adult she was left with serious scars of her legs and arms. The mother then began abusing a younger brother in a similar manner. The girl grew up to be a nurse, got married, and had two children. Years of therapy helped but did not erase the physical scars or all of the psychological scars.

Covert Video Surveillance MSBP encompasses a wide variety of presentations, and some of them are more easily detected than others. For non-legal professionals, it can be easier to make a diagnosis if the perpetrator is caught adding substances to an IV line or smothering a

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child, a poison is detected on drug screening, and other overt acts are committed. Many presentations do not have such overt acts and the diagnosis is more inferential (e.g., medicines that should work do not, the supposed illness is only seen by the perpetrator, etc.). The tendency to want to find a “smoking gun” may be stronger in the legal setting. Convincing a judge or jury that child abuse was done can be easier if a definitive action that cannot be misinterpreted is documented. Covert video surveillance in a hospital may capture a perpetrator committing an act or the caregiver/child acting differently than when others are around. For example, a hidden camera may record a child who supposedly has problems eating solids, enjoying food snuck into a room by a family member. It might show a child being suffocated by a caregiver shortly before the monitors indicate an episode of apnea. It might show a child who does not have seizures. For these multiple possibilities, a video recording of tampering or behaviors not in accord with the reported medical problem can be useful in more definitively proving the case. Covert video surveillance (CVS) is accomplished by having a hidden camera in a specially designated patient room. Ideally there would be several cameras with different angles. They would ideally be high resolution to minimize different interpretations of what is occurring. In some instances, such a room has been equipped with an infrared camera which allows surveillance even when the lights are low or off. When CVS is used, it is important that someone (usually security) constantly monitor what is occurring. Should there be some health or life-threatening event, the hospital should be able to immediately intervene into the room to stop the action and preserve the health or life of the child. Because of the cost of the equipment and the need for dedicated constant surveillance, there are not many hospitals able to offer this option. Epstein et al. (1987) reported an 18-month-old boy who was evaluated for intractable diarrhea. He had had multiple hospitalizations without a definite diagnosis. A stooling pattern that occurred during waking hours but not when sleeping or when he was out of the room for diagnostic procedures aroused suspicion. CVS was used and showed the mother emptying the contents of a syringe into the child’s mouth on several occasions. The mother was confronted by a staff member and security officer, and the room searched. Multiple medications capable of causing diarrhea were found. Upon separation from the mother, the diarrhea ceased. Multiple preparations had been made with hospital doctors, administration, and lawyers to determine the best course in the process of covert video recording which was believed essential in making the diagnosis and protecting the child from continued harm. Southall et al. (1987) used CVS in 2 hospitals for a total of 39 children in which there were suspicions of induced illness. Thirty-six were referred for investigation of “apparent life-threatening event” (ALTE), now referred to as “brief resolved unexplained event” (BRUE). CVS documented intentional suffocation in 30 patients. Poisoning, a deliberate fracture, and other emotional and physical abuses were also seen. Of the 39 patients, there were 41 siblings of whom 12 died suddenly and unexpectedly. A group of control patients did not show such findings. They

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noted that bleeding from the mouth or nose was a particular sign for induced suffocation. Byard and Burnell (1994) presented a case of asphyxia by a mother in which CVS was used. There had been two previous sudden infant deaths in the family and unexplained apneic episodes in the patient. CVS showed the mother to be asphyxiating the infant. While she initially denied her actions, she eventually pled guilty to manslaughter of the first infant and grievous harm to the patient. The authors argued that other interventions could have compromised the investigation and caused unacceptable delays – placing the patient at risk. Hall et al. (2000) reported 41 cases in which CVS was used to attempt to identify MSBP. Based on CVS, 23 of the 41 cases were identified as such. Thirteen of the 23 cases were judged to have required CVS to make the diagnosis, and in 5 cases CVS was supportive. In four instances, CVS helped to establish that the diagnosis was not MSBP. Looking at patients with medically unexplained symptoms, Wallace et al. (2012) discussed a 12-year-old boy who presented with a progressive neurologic decline and chronic pain. Medical testing was unrevealing. CVS was used and showed that he had greater abilities when alone in his room than when medical personnel were present. Subsequent treatment was informed and was helpful. An additional three teenage patients also had CVS for medically unexplained symptoms. It was felt that medically important information was obtained. Most cases of medically unexplained symptoms do not require CVS. The authors discussed ethical and legal considerations in the use of covert recording. This is a use of CVS that shows its utility in non-MSBP patients as a means for obtaining information about what might really be happening. Several issues with CVS have been debated. An obvious concern is patient physical privacy. What if a patient is changing clothes? Might a recording of this be an infringement? Because these are medical recordings conducted with hospital security, there should not be any danger they would show up on social media. However, they could be seen by legal authorities in the course of a case. Another issue is consent. By definition the parent is unaware that there is recording. Is this an intrusion? A key solution to privacy and consent begins with the basic hospital consent form. Many hospitals in the initial hospital consent forms announce that there are cameras in the hospital and that they might be recorded at any time in a public space. A hospital room is considered a public space. A nurse, technician, doctor, or others might enter at any time. In contrast, a bathroom is not a public space and would not be acceptable for recording. In several instances, CVS shows a child being taken into a bathroom and then emerging with symptoms – a compelling indication of awareness of wrongdoing. Another concern is when CVS is indicated. A hospital attorney might argue that despite constant surveillance, CVS is documentation of harm. How long does a child have to be suffocated before there is enough documentation that this is occurring? Might this be a record of a child being harmed in a hospital – with some indication that the hospital allowed it for purposes of documentation of harm vs. prevention of

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harm? If there is enough suspicion of MSBP, why use CVS? Why not diagnose it and report it? What if nothing happens? Does this mean that in other settings there is not an overt action leading to harm? Foreman and Farsides (1993) cited concerns with CVS including exposure of the child to further abuse and a breach of trust between the carer, the child, and the professionals. They discouraged its use. Evans (1994) regarded CVS as forensic, not medical, and questioned the proper role of a doctor. He regarded this as research. Southall and Samuels (1995) argued that the need to establish the diagnosis under selected circumstances and with proper procedure was ethical. Gillon (1995) discussed the various ethical considerations and emphasized the need for an ethics committee to review how this is to be done. Yorker (1995) presented a legal analysis that a hospital room has no reasonable expectation of privacy. She cited “exigent circumstances” – the need for a diagnosis in the face of possible fatality as a countervailing interest balanced against the parent’s right of privacy. Thomas (1996) detailed the use of the Staffordshire protocol as providing important guidance when conducting CVS. Connelly (2003) stated that the use of CVS was morally questionable. He pointed out that CVS “involves deception and policing objectives that compromise not only parent rights but the role of medicine itself.” He emphasized the concept of parent’s rights – seemingly at the expense of the actual patient – the child. Ethical arguments can be found throughout the practice of medicine. Child abuse entails the overlap of the health and safety of the child (child abuse pediatrics) with similar concerns by child protective services, law enforcement, lawyers, and the police. Connelly’s (2003) arguments artificially limit the scope of pediatrics – conflating the need for medicine to probe what is in the best interests of the child with an “investigative” approach by others. It is important that a hospital wishing to use CVS have a written protocol as to entry criteria and how CVS will be done. It should be reviewed by child abuse pediatrics, an ethics committee, and community partners. There should be a retrospective review of cases to determine if the protocol meets the purposes intended as CVS is used.

Case Management An important question is whether MSBP is “treatable.” It is advantageous to have a psychological assessment of the perpetrator, not because MSBP is a mental health disease, but to determine mental health problems that may exist. For example, what if a mother actually has a delusion that there is a demon in her child’s belly? She might exhibit MSBP type of behaviors but the motivation is explained by another condition. It is possible that she might have schizophrenia as the reason for her beliefs and behaviors. Such conditions might be treatable, whereas there is considerable controversy whether attempting to “treat” MSBP by mental health means is reasonable or works. Because MSBP is a form of child abuse, first consideration might be to the approach as with other forms of child abuse. Since a child is physically harmed (unnecessary needle poke at a minimum), legal sanctions could be considered. The

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risk of fatality is relatively high (up to 10% of the egregious cases reported in the literature). The odds that the child will be psychologically healthy are virtually nil, when a full-blown case of MSBP occurs (McGuire and Feldman 1989; Sanders 1996; Stirling et al. 2007; APSAC 2018). Immediate termination of parental rights would reflect the seriousness of the situation and the harm to the child. Criminal sanctions could be considered. Despite the possible legal sanctions approach, explicitly or implicitly child protective services and the courts often approach this as a situation in which social services and/or mental health services might remediate the perpetrator while a plan could be made to keep the child safe. The American Professional Society on the Abuse of Children (APSAC) issued guidelines for services and treatment should they be pursued (APSAC 2018). Paramount is the protection of the child. Only in rare cases has treatment been shown to be effective. Typically this entails an early admission of what happened, identification of why the abuse happened, and correcting these motivations in the perpetrator. It requires essentially re-making the parent into another person who is safe for the child. Should this be pursued, the following professionals should be knowledgeable about MSBP: 1. 2. 3. 4.

Lawyers and judge(s) Pediatrician treating the child Therapist for the mother Any therapists for the child and family

It is important that caregivers and professionals accept the diagnosis and not sabotage the attempt for remediation. The mother cannot participate in or be responsible for any medical care of the child or any other child. The APSAC guidelines further specify: a professional familiar with the case and with the court orders should closely monitor all visitations in a neutral location. 1. The suspected abusers (and related caregivers) should not discuss health-related issues, including diet, with their child. 2. They should not give their child food, drinks, candy, gum, lotions, or medicine. 3. They should not attempt to influence the child to distrust children’s services staff, his or her foster family, or treatment team. 4. The child should be visible at all times. 5. All conversation must be audible to the monitor. 6. All physical contact must be developmentally and socially appropriate. 7. All gifts and cards must be socially and developmentally appropriate, with only one gift allowed per visit and examined before it is provided to the child. Bursch, Emerson, and Sanders (2019) provided detailed guidance to psychologists and other mental health providers about their role in such cases. It is important not to be manipulated while providing evidence-based therapies to re-orient the perpetrator and victim.

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Legal Issues MSBP often is difficult for courts to understand. One tendency is to see this as a psychological problem. Surely a parent must be mentally ill to do such things to a child? Yet the same superficial argument could be made for other forms of child abuse. Like MSBP, much sexual abuse entails planning – not impulsive angry behaviors seen with most physical abuse. It is more akin to torture as well. MSBP is child abuse, not a mental health diagnosis. When presenting MSBP to legal authorities, a circumstantial medical diagnosis can be difficult to comprehend and places reliance on the opinion of the medical expert. The “smoking gun” is preferred and sometimes legal authorities are hesitant to proceed in its absence. Unlike some abuse diagnosis, the existence of MSBP itself may go on trial. Attacking the concept of MSBP takes multiple forms. 1. The different names used for this condition may be held up as showing uncertainty in the field about whether this is really a syndrome at all and if the criteria for diagnosis are too fluid. 2. Attacks may be made on the doctors. It has often been claimed that when doctors don’t know what the diagnosis is, they call it MSBP. 3. Overdiagnosis may also be a legal argument. While acknowledging the video recordings and findings such as poisons are legitimate, a claim might be made in other instances that the mother is exaggerating and doesn’t understand the medical system. Doctors then misunderstand them and inappropriately rush to a wrong judgment. Because it is doctors who regularly work with parents of different intellectual, social, and cultural background, this criticism in the legal arena by those with no clinical experience is seen as misplaced. 4. The question might be whether every test has been done to rule out an alternative medical diagnosis. The hazard of this is that it feeds into the on-going abuse of the child by medical means while chasing ephemeral likelihoods. When pursued, this can lead to the sanctioning for further abuse. When testifying about MSBP in court, it is often advantageous to label it as “child abuse.” It can further be said that it fits as form of child abuse called MSBP. Or it might be that the child abuse has features of MSBP – but maybe not a perfect fit. Maybe it is neglect and not exactly deceptive – not MSBP. The key is whether the child is abused in some manner – not the justification of a specific label. MSBP is useful in helping the court understand that such forms of child abuse exist. It is especially useful when discussing prognosis and treatment possibilities if that occurs. In juvenile court, the expert can discuss the dismal prognosis in full-blown cases and the plan can be how to deal with that. In criminal cases, the harms and threatened harms can be better elucidated when an MSBP pattern is established. Legal challenges to physicians making the diagnosis of MSBP are not rare. Roy Meadow testified in several cases of Munchausen by proxy including three highly publicized cases that were later overturned. Dr. Meadow’s medical license was

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revoked by the General Medical Council in 2005, only to be reinstated the following year. A similar suspension of medical licensure over MSBP cases and then reinstatement by the General Medical Council occurred with David Southall who pioneered covert video surveillance (Chadwick et al. 2006; Galvin et al. 2005). Other physicians in the USA have had legal actions brought against them in MSBP cases – perhaps perpetuating the attention seeking of the perpetrator but in a legal, not medical, arena.

Future Prevention of MSBP would be the best public health option given the cost, morbidity, and mortality. Primary prevention might anticipate and halt behaviors before MSBP is manifested in a full-blown manner. Physicians could be trained to take more complete and focused histories even in the face of pressures to see patients quickly. Treatment of medical child abuse (Roesler and Jenny 2008) before it starts or in its early stages might avert MSBP. Understanding the motivations and modifying the behaviors might require intensive family therapy by experts, and this could be difficult for families not able to spend weeks away from work. However, given the medical costs of MSBP, an intensive program might be cost effective and, if successful, prevent harm to a child. Secondary prevention focuses on high-risk groups. Because physicians are inadvertent enablers in many instances when a perpetrator enlists their help, specific specialties could teach parents on appropriate means to enlist their attention. Before embarking on ambitious testing regimes, physicians could focus more on possible parent motivations. Tertiary prevention consists of early case detection. Young patients presenting with unexplained seizures, bleeding, and gastrointestinal problems deserve extra consideration for detailed histories, and there should be greater reluctance for medications or procedures. Electronic medical records and insurance records could be devised to flag an unusual number of hospitalizations or other parameters that might suggest MSBP could be occurring. Artificial intelligence could be used to refine these algorithms to increase sensitivity and specificity. The goal would be to establish a better screen, not replace a diagnosis by a sophisticated team. Social media increasingly is a platform for perpetrators to share stories and techniques. Police and other investigators have used this to identify patterns retrospectively (Esernio-Jenssen et al. 2018), but it might be possible to prospectively monitor such sites and thereby identify cases as yet unknown. Child protective services and judges need more training. Cases continue to exist in which fundamental misunderstandings about MSBP impair the health and safety of children. Legislation to establish child protection specialists can be accomplished. Legislation can also toughen the penalties for lying to a medical professional resulting in harm to a child. In practice, MSBP cases are dealt with in juvenile court and occasionally in criminal court when harm to the child is established. The act of lying itself is not a penalty despite it being the means to risk the child’s health and

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well-being. Lying to a medical professional in a clinic could be a misdemeanor and in a hospital it could be a felony. This would allow medical professionals to stress how important it is to tell the truth. Until such time that the needs of a caregiver can be met in more fruitful ways than using the medical system to harm their child, MSBP will continue to be a rare but serious risk.

Key Points • MSBP is a rare and serious form of child abuse. • It is not a mental health disorder, but co-existing or superseding mental health conditions should be identified if present. • Virtually any medical condition can be lied about or faked in some fashion. • The child is harmed by the inappropriate medical attention leading to unnecessary tests and interventions. In the process of faking a medical condition, the caregiver may harm or kill the child. • Treatment of MSBP is difficult and has a poor prognosis.

Summary and Conclusion MSBP is a rare but serious form of child abuse. The perpetrator is usually the mother, who uses her child to gain medical attention to meet her own needs. Lies and/or overt deceptions lead to unnecessary medical tests and interventions. The mother may directly harm her child by suffocating, introducing pathogens in IV lines, or administering poisons. Detection is fortuitous and may not occur until many hospitalizations or surgeries occur. In some instances where the diagnosis remains a question, covert video surveillance may clarify. Investigation of social media, school records, veterinary records, or the mother’s own medical records may yield important information. APSAC guidelines can assist if an attempt is made to remediate the perpetrator, but in most cases the denial is strong and the prognosis dim. Knowledge about MSBP is important for pediatric medical providers. Early detection is important to minimize the harm to the child created by the caregiver. With early intervention, it is possible that an intensive remediation program might preserve the health and mental health of the child. In many instances, an alternative placement will be necessary to ensure the child’s health and safety.

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McGuire, T. L., & Feldman, K. W. (1989). Psychological morbidity of children subjected to Munchausen syndrome by proxy. Pediatrics, 83, 289–292. Meadow, R. (1977). Munchausen syndrome by proxy – The hinterland of child abuse. Lancet, 2, 343–357. Meadow, R. (1998). Munchausen syndrome by proxy abuse perpetrated by men. Archives of Disease in Childhood, 78, 210–216. Meadow, R., & Lennert, T. (1984). Munchausen by proxy or Polle syndrome: Which term is correct? Pediatrics, 74, 554–556. Munro, H. M. C., & Thrusfield, M. V. (2001). ‘Battered pets’: Munchausen syndrome by proxy (factitious illness by proxy). Journal of Small Animal Practice, 42, 385–389. Roesler, T. A., & Jenny, C. (2008). Medical child abuse: Beyond Munchausen syndrome by proxy. Elk Grove Village: American Academy of Pediatrics. Rosenberg, D. A. (1987). Web of deceit: A literature review of Munchausen syndrome by proxy. Child Abuse & Neglect, 11, 547–563. Royal College of Paediatrics and Child Health. (2009). Fabricated or induced illness by carers (fii): A practical guide for paediatricians (PDF). London: Royal College of Paediatrics and Child Health (RCPCH). Sanders, M. J. (1996). Narrative family therapy with Munchausen by proxy: A successful treatment case. Family, Systems, and Health, 14(2), 315–329. Sheridan, M. (2003). The deceit continues: An updated literature review of Munchausen syndrome by proxy. Child Abuse & Neglect, 27, 431–451. Southall, D. P., & Samuels, M. P. (1995). Some ethical issues surrounding covert video surveillance – A response. Journal of Medical Ethics, 21(2), 104–105. 115. Southall, D., Plunkett, M., Banks, M., Falkov, A., & Samuels, M. (1987). Covert video recordings of life-threatening child abuse: Lessons for child protection. Pediatrics, 100, 735–760. Steinschneider, A. (1972). Prolonged apnea and the sudden infant death syndrome: Clinical and laboratory observations. Pediatrics, 50, 646–654. Stirling, J., & American Academy of Pediatrics Committee on Child Abuse and Neglect. (2007). Beyond Munchausen syndrome by proxy: Identification and treatment of child abuse in the medical setting. Pediatrics, 119, 1026–1030. Sullivan, C., Francis, G., Bain, M., & Hartz, J. (1991). Munchausen syndrome by proxy: 1990: A portent for problems? Clinical Pediatrics, 30, 112–116. Thomas, T. (1996). Covert video surveillance – An assessment of the Staffordshire protocol. J. Med Ethics, 22, 22–25. Verity, C. M., Winckworth, C., & Bruman, D. (1979). Polle syndrome: Children of Munchausen. British Medical Journal, 2, 422–423. Wallace, D., Sim, L., Harrison, T., Bruce, B., & Harbeck-Weber, C. (2012). Covert video monitoring n the assessment of medically unexplained symptoms in children. J Pediatric Psychology, 37, 329–337. Yates, G., & Bass, C. (2017). The perpetrators of medical child abuse (Munchausen syndrome by proxy) – A systematic review of 796 cases. Child Abuse & Neglect, 72, 45–53. Yorker, B. C. (1995). Covert video surveillance of Munchausen syndrome by proxy: The exigent circumstances exception. Health Matrix: Journal of Law – Medicine. Case Western Reserve University Law Review, 5(2), 325–346.

Corporal Punishment: Finding Effective Interventions

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Discovery of Childhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Child Protection Movement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Estimates of Corporal Punishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Correlates of Corporal Punishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Harm and Ineffectiveness of Corporal Punishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interventions to Reduce Corporal Punishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alternatives to Physical Discipline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Worldwide Movement to End Corporal Punishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Corporal punishment, which is defined as inflicting pain or discomfort as a form of discipline (e.g., hitting, holding hands in the air for extended periods of time, etc.), continues to be commonly practiced around the world. Worldwide estimates are that 60% of children have experienced mild physical punishment in the previous month, and 20% experienced severe punishment (UNICEF. Hidden in plain sight: a statistical analysis of violence against children. https://data.unicef. org/resources/hidden-in-plain-sight-a-statistical-analysis-of-violence-against-chil dren/. Accessed July 2019, 2014). In the United States, where corporal punishment is especially common compared to other wealthy democracies, an estimated

This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. R. D. Perrin (*) · C. Miller-Perrin Pepperdine University, Malibu, CA, USA e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_26

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80% of parents have spanked their child at some point during their child’s life (Gershoff et al. Child Dev 83(3):838–843, 2012). This chapter documents the accumulating empirical evidence that corporal punishment is not only unnecessary as a disciplinary technique, but also potentially harmful to children. This accumulating evidence has led to a worldwide movement to eliminate its use. Keywords

Corporal punishment · Spanking · Child abuse · Social construction of childhood · United Nations convention on the rights of the child · Physical discipline · Discovery of childhood

Introduction Social problems are socially constructed. This is not to say that any issue society might deem important or tragic, like child abuse for example, is fake, or imagined, or made up. It simply means that societal reactions are central to the process of recognizing and defining a social problem like child abuse. How does one, for example, define child? How does one define abuse? How does child abuse become deemed a social problem? The answers to these questions do not fall from the sky. Through societal debate and argument, societies construct definitions of concepts like “child” and “abuse.” A “social problem” like child abuse is essentially “discovered” through this process of societal reactions and social definition. Not all hitting of children, of course, is judged “abusive.” In many cultures, the hitting of children and other forms of corporal punishment are accepted as long as they are understood to be “non-injurious” and “corrective.” Corporal punishment, which is defined as any form of physical punishment in which “physical force is used and intended to cause some degree of pain” (UN Committee on the Rights of the Child, General Comment No. 8 2006, p. 4), can take numerous forms. A child can be physically punished actively (“spanked,” or “swatted,” with a hand or object) or physically punished in more passive ways (e.g., forcing a child to stand with hands raised in the air for an extended period of time). Of course these physical punishments inevitably exist on a continuum that varies by degree. A parent could “spank” the clothed bottom of a child with an open hand a couple of times, or hit the bare bottom of a child with a leather belt multiple times. A parent could force a child to stand in the corner with arms raised for 5 min or for an hour. A common practice like corporal punishment is fascinating to examine from a social constructionist perspective. Until perhaps the last 50 years or so, the effectiveness and necessity of corporal punishment was largely unquestioned. Today, however, corporal punishment is widely recognized by social scientists as causing more harm than good (Gershoff and Grogan-Kaylor 2016b) and there is a worldwide movement to eliminate its use (The United Nations 1989). Many child-centered professional organizations in the United States, including both the American

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Pediatrics Association and the American Psychological Association, have passed resolutions recommending against the use of corporal punishment, and it is criminalized in 56 countries (Global Initiative to End all Corporal Punishment of Children 2019). This chapter addresses how “we” – most Americans, and most people around the world – arrived at our current understanding of corporal punishment. To provide historical context for current-day understandings of corporal punishment, the chapter first addresses the “discovery” of childhood and the birth of the child protection movement. Estimates of current rates of corporal punishment are discussed along with demographic factors related to it. The current state of empirical research on what is known about the harm and ineffectiveness of corporal punishment is also described. Interventions to reduce corporal punishment are summarized along with effective alternative disciplinary strategies. Finally, the chapter ends with a description of the worldwide movement to end the use of parental corporal punishment

The Discovery of Childhood In order to put current understandings and practices of corporal punishment in context, it is important to review the history of childhood and of hitting children. Even a cursory look at this history reminds us that children have not always been valued and protected, and childhood has not always been seen as a special phase of life. This observation is most commonly attributed to French medievalist historian Philippe Aries who, in his widely cited book Centuries of Childhood (Aries 1962), argues that in the medieval world there was, essentially, “no place for childhood” (Aries 1962, p. 33). Life was difficult, child mortality rates were high, and children were often seen as economic burdens. Throughout much of history, children were regarded as little more than miniature adults. When they were old enough to be recognized as an economic asset, they were put to work. When they were punished, they were punished as adults were punished (deMause 1974; Pagelow 1984; Piers 1978). For Aries (1962), it is not that children in the medieval world were necessarily “neglected, forsaken, or despised” (p. 128). A better word, he suggests, is indifference; an indifference that was a “direct and inevitable consequence of the demography of the period” (p. 38). Others, however, describe a more ominous history. According to deMause (1974), for example, the history of childhood is a “nightmare from which we have only recently begun to awaken” (p. 1). The further back in history one goes, he writes, “the lower the level of child care, and the more likely children are to be killed, abandoned, beaten, terrorized, and sexually abused” (p. 1). One illustration of this history is the practice of infanticide, which some scholars maintain was the most frequent crime in all of medieval Europe (Piers 1978). Babies who were too big or too small, cried too much, had physical defects, or were simply unwanted were often killed or abandoned. Not surprisingly, given the historical indifference to women, female infanticide was especially common (deMause 1974; Piers 1978).

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The Child Protection Movement Given this history of indifference toward children, it should come as little surprise that child protection laws evolved slowly over time and are a product of the past few centuries. Indeed, child abuse could not be discovered until childhood was discovered. While a detailed account of the history of child protection laws is well beyond the scope of this chapter, it might be helpful to detail a few important events in the child protection movement. Perhaps the best place to begin is with the legal principle of parenspatriae (“parent of the nation” in Latin), which gives the state the power and responsibility to defend and protect those who cannot defend and protect themselves. This legal principle arms governments with a statutory basis to protect children and to intervene in parental practices deemed abusive (Piers 1978). Within The Massachusetts’s Body of Liberties, which is a seventieth century legal code established by the colonists, we find an early and important attempt to apply parenspatriae. A parent, according to The Body of Liberties, could not inflict any “unnatural severity” on a child (Pleck 1987). However, in a very important caveat, the law could only be enforced if the child was considered completely blameless. The Puritans, like many conservative Christians today, believed that children are, by nature, incorrigible, defiant, and predisposed to wrongdoing. As stated in the Old Testament Book of Proverbs (22:15), “Folly is bound up in the heart of a child, but the rod of discipline will drive it far away.” As another sign of how the Puritans viewed childhood defiance, the Body of Liberties permitted the death sentence for any child over the age of 16 who had cursed at, or struck, a parent. Although the law was likely never enforced, its existence most certainly illustrates the Puritans’ intolerance of defiant behavior (Pleck 1987). It also illustrates that seventieth century colonists could hardly be seen as child protection champions. In 1874, the child protection movement gained national attention with the legal case of 8-year-old Mary Ellen Wilson. Etta Wheeler, a devoted Christian and advocate for the poor, had discovered that Mary Ellen, who had been abandoned by her birth mother, was being physically abused by her guardians. Wheeler approached the police, who were unwilling to prosecute. Child charity organizations were not equipped to help. So Wheeler turned to Henry Bergh, who in 1866 had founded the Society for the Prevention of Cruelty to Animals. Bergh, the influential son of a wealthy U.S. diplomat, had successfully lobbied for laws to protect animals from abuse, but had been criticized for not taking an interest in children (who were, after all, also members of the animal kingdom). At Wilson’s urging, Berg advocated for Mary Ellen’s case and arranged for the successful prosecution of her abusers (Myers 2008). The primary reason the case is so famous is because Wheeler sought help from the man who had created an organization that protected animals because there were no similar organizations committed to protecting children, and there were few legal protections of children at the time. After the trial, Wilson lobbied Berg about these inadequacies, and he, along with leading reformer Elbridge Gerry, founded the New York Society for the Prevention of Cruelty to Children (Myers 2008; Pagelow 1984).

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Child protection once again garnered attention in the 1960s, when Dr. C. Henry Kempe and his colleagues published the “Battered Child Syndrome” in the Journal of the American Medical Association (Kempe et al. 1962). The clout of the American Medical Association proved influential, and in 1974 Congress passed the Child Abuse Prevention and Treatment Act (CAPTA). CAPTA, which has been reauthorized and amended several times (most recently in the Child Abuse Prevention and Treatment Act of 2011), mandates that state-level child protection services (CPS) agencies investigate suspected incidents of child maltreatment. CAPTA also provides federal funding and guidance for research and services related to child protection (Child Welfare Information Gateway 2019).

Estimates of Corporal Punishment It is true that the indifference and abuse of the past have, in modern times, largely been replaced by a belief that children are precious and vulnerable, and should be loved and nurtured. Yet, it is hard to hide from the past. Children have always been hit. Although distinctions have evolved between legal and illegal forms of corporal punishment (e.g., between “abuse” and “discipline”), throughout much of the world hitting children continues to be endorsed and practiced. Worldwide estimates of corporal punishment, while especially complicated, are that 60% of children have experienced mild physical punishment (defined as spanking, hitting, or slapping with a bare hand; hitting or slapping on the hand, arm, or leg; shaking; or hitting with an object) in the previous month, and 20% experienced severe punishment (hitting on the head, ears, face, or hitting the child hard or repeatedly) in the past month (UNICEF 2014). Corporal punishment is most common in low- and middle-income countries in Eastern Europe, Asia, and Africa (Grogan-Kaylor et al. 2018). In one survey of households in several low- and middle-income countries, for example, Cuartas and colleagues found over 60% of children ages 2–4 years were exposed to physically aggressive discipline, and the rates were highest in the poorer countries in the survey (Cuartas et al. 2019). In a massive study involving interviews of 1398 mothers, 1146 fathers, and 1417 children (age range to 10 years) from nine countries (including China, Colombia, Italy, Jordan, Kenya, the Philippines, Sweden, Thailand, and the United States), a team of international researchers found that 54% of girls and 58% of boys (ages 7–10) had experienced mild corporal punishment and 13% of girls and 14% of boys had experienced severe corporal punishment in the past month (Lansford et al. 2014). Not surprisingly, the rates varied dramatically across countries. In Sweden, for example, where corporal punishment is illegal, fewer than 10% of children experienced mild corporal punishment in the previous month, and none were severely punished. In Kenya, on the other hand, almost all children (90%) experienced mild corporal punishment in the previous month, and 60% had been severely punished. In the United States, 37% reported mild violence and 4.5% reported severe violence in the previous month. The nine countries, ordered from most likely to

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severely punish to least, were Kenya, Jordan, Italy, China, Columbia, Philippines, United States, Thailand, and Sweden (Lansford et al. 2014). In the United States, support for corporal punishment continues to be widespread. According to the General Social Survey, 70% of Americans agree or strongly agree that it is “sometimes necessary to discipline a child with a good, hard spanking” (Smith et al. 2019). The key words in this sentence are good hard and necessary. U.S. parents, overwhelmingly, believe that it is sometimes necessary to give a child a good hard spanking? This is, in many respects a shocking attitudinal pattern. Given these high rates of attitudinal support, it is not surprising that most parents spank their children. Gershoff and colleagues (2012), for example, estimate that 80% of U.S. parents have spanked their child at some point during their child’s life. In a recent nationwide survey conducted by Finkelhor and colleagues (2019), approximately one-half of parents of children ages 2– 8 reported that they “had to spank or slap” their child to “get him/her to behave” in the past year. Rates of spanking varied depending on the age of the child. At the age of 2, approximately 50% of parents spanked in the past year. The rates increased to 60% for 3– 4 year olds and were still at 50% for 8 year olds. After the age of 8, rates declined significantly; approximately 20% of parents reported hitting their 13-year-old child in the past year, and approximately 10% of parents reported hitting their 17-year-old child in the past year.

Correlates of Corporal Punishment Several demographic and sociocultural factors are predictive of corporal punishment. Mothers spank more than fathers, which may be because mothers spend more time with their children than fathers (Lee et al. 2015). Younger parents spank more than older parents, which may be because young parents are less mature, less confident, and more stressed about parenting (Trillingsgaard and Sommer 2018). Low education levels and low family income are also correlated with corporal punishment, which may in part reflect the higher level of stress in their lives and less knowledge of the potential harm of corporal punishment (Conrad et al. 2019). Rates of corporal punishment also vary across racial and ethnic groups, with African-American parents, in particular, reporting higher rates of spanking (Finkelhor et al. 2019), which may be due to cultural variation in the acceptance of spanking as a practice, that is, a normal part of parenting (Gershoff and GroganKaylor 2016a). Finally, corporal punishment also varies by geographic region, with parents in the South reporting higher rates of spanking than those living in the Northeast or West (Finkelhor et al. 2019). Conservative Christians, especially evangelical Protestants, are more likely to spank (Hoffman et al. 2017; Vieth 2014). Two factors contribute to this pattern. First, a few passages in the Bible, primarily in the Old Testament book of Proverbs (e.g., 13:24, 22:15, 23:13–14), are interpreted by some conservative Christians (who are more likely to interpret the Bible literally) as a mandate to spank. A second contributing factor is that many conservative Christians believe that children are prone to egocentrism and sinfulness at birth, and physical punishment plays an

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important role in “shaping the will” of the inherently rebellious child. The child’s submission essentially serves as a model for a future relationship with God (Abelow 2011). Recall that this belief is reflected in early child abuse laws (e.g., The Body of Liberties from the seventieth century), which protected children from abuse only if the child was seen as completely blameless. Many conservative-leaning pro family organizations, including for example Focus on the Family and the Family Research Council, actively promote spanking as an effective and God- endorsed form of discipline. James Dobson, who founded Focus on the Family in 1977, is perhaps the most prominent evangelical advocate of spanking (Dobson 1970, 1978). Even in Dobson’s absence (he stepped down as Chairman in 2009), Focus on the Family has continued to promote spanking as a biblically endorsed form of discipline (Ingram n.d. In the extreme, some Christian leaders have even promoted a form of physical discipline that can only be described as abusive (e.g., Pearl and Pearl 1994). Although it is impossible to deny the impact some forms of Christianity have had on pro-spanking attitudes, it is also important to recognize the various ways Christianity, and religion more generally, have had a positive influence. For example, the high-risk single mothers from the Fragile Families and Wellbeing study (https:// fragilefamilies.princeton.edu/parents) who attended church regularly were less likely to use physical punishment than mothers who did not attend religious services at all (Petts 2012). Parents who report “spiritual experiences” also report less use of physical punishment (Grogan-Kaylor et al. 2018). Finally, two of the largest and most influential Protestant denominations in the United States, the Presbyterian Church USA and the United Methodist Church, have in recent years passed resolutions urging parents not to spank their children (Vieth 2014).

Harm and Ineffectiveness of Corporal Punishment Parents likely continue to spank their children because they believe it is harmless and is an effective method for stopping undesirable behavior. Empirical research, however, contradicts these beliefs. Decades of research overwhelmingly lead to the conclusion that spanking does more harm than good. Gershoff and Grogan-Kaylor’s meta-analysis (2016b) examined 50 years of research encompassing more than 500 studies on outcomes associated with spanking. It found (a) no evidence that nonabusive spanking is effective at improving child behavior and (b) evidence that spanking was associated with increased risk for 17 harmful outcomes. Although not every incident of spanking results in negative outcomes, the preponderance of evidence clearly suggests that spanking is ineffective and is a significant risk factor for negative developmental outcomes. Spanking and hitting children is a risk factor for lower long-term child compliance, increased child aggression and other behavior problems, mental health problems, lower cognitive performance, and lower parent– child relationship quality (Gershoff et al. 2018b; Gershoff and Grogan-Kaylor 2016b). Spanking increases the risk of physical abuse, and in itself leads to detrimental outcomes comparable to those associated with physical abuse and other

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adverse childhood experiences (Afifi et al. 2017; Gershoff and Grogan-Kaylor 2016b). These findings have also been observed in cross-cultural studies which have included individuals from several different countries (Pace et al. 2019). The detrimental outcomes associated with spanking not only impact children, but also extend into adulthood and may spill over into society. Afifi et al. (2017), for example, studied various adult mental health problems in a sample of over 8,000 adult members of a large healthcare maintenance organization in southern California and found that spanking was associated with increased risk for suicide attempts, moderate to heavy drinking, and use of street drugs. The increased risk for these mental health problems when participants had been spanked persisted even after taking into account physical and emotional abuse experiences. There is also evidence that both physical punishment and positive social attitudes toward it are associated with higher levels of social violence, such as dating violence, bullying, interpersonal violence (e.g., Poulsen 2018). Although conducting experimental studies evaluating the causal relationship between physical punishment and detrimental outcomes is not ethically possible, longitudinal studies demonstrate that spanking predicts deterioration rather than improvement in children’s behavior problems over time (e.g., Grogan-Kaylor 2005). In addition, studies using statistically rigorous controls for confounding variables (e.g., sociodemographic, family, and cultural characteristics) have found that increases in spanking predict increases in negative child outcomes (Gershoff et al. 2012). These findings have led experts in the field to conclude that the negative consequences of physical punishment of children are consistent and unequivocal (e.g., Gershoff et al. 2018b).

Interventions to Reduce Corporal Punishment Professionals have developed a range of interventions designed to eliminate or reduce corporal punishment (for a review see Gershoff et al. 2017). These interventions vary in strategy, content, and style, but most are based on two key inferences from research, as well as one important moral assumption. The first inference is that physical discipline is potentially harmful to children. The second is that nonviolent disciplinary strategies are more effective than spanking. The moral assumption is that children should never be hit. Some interventions focus on changing positive attitudes toward or intentions to use corporal punishment, others focus on enhancing knowledge about effective nonviolent disciplinary practices and the potential harm of corporal punishment, and still others focus on reducing parents’ use of physical discipline. In one study, the Play Nicely program, an interactive multimedia intervention that teaches alternatives to physical punishment, decreased parents’ positive attitudes toward spanking and intentions to use spanking as a disciplinary technique (Scholer et al. 2010a). In another study, first-time mothers received baby books that educated them about effective alternatives to physical punishment and also about typical child development. Compared to mothers who received noneducational baby books or no

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books, mothers who received the educational baby books reported significantly less favorable views toward physical punishment. These effects were strongest for African-American parents and parents with low levels of education attainment (Reich et al. 2012). Changing individuals’ attitudes before they become parents is another important strategy to reduce spanking. Educating college students about the ineffectiveness and potential problems associated with physical punishment can significantly decrease students’ favorable attitudes about and behavioral intentions to use physical punishment (Robinson et al. 2005). Similarly, nonparents who read a brief research summary about the ineffectiveness of and potential harms linked to physical punishment significantly decreased their favorable attitudes about and behavioral intentions to use physical punishment compared with controls (Holden et al. 2014). Some interventions focus on challenging religious attitudes and beliefs that promote spanking. As discussed above, Christians generally, and conservative Protestants specifically, are more likely than other parents to support and practice physical punishment (Ellison et al. 2011; Vieth 2014). Therefore, it is important to present a reinterpretation of biblical scriptures that are often interpreted as a mandate to spank. Miller-Perrin and Perrin (2018), Perrin et al. (2017) attempted to change positive attitudes toward spanking among groups of college students attending a conservative Christian university. Their interventions included various combinations of written material and oral presentations on the ineffectiveness and potential harm of spanking, as well progressive interpretations of biblical passages related to spanking children. They found the greatest attitudinal change among those highly religious students who were exposed to both the empirical evidence as well as progressive reinterpretations of the relevant biblical passages One significant limitation to the research described above is that intervention outcomes focused on attitude change and/or behavioral intentions rather than actual behavior. Although there is potential value in targeting attitudes and intentions, the ultimate measure of an intervention’s success in reducing corporal punishment would be to assess actual change in spanking behavior. One approach to reducing the frequency of physical punishment among parents who use physical punishment is the Adults and Children Together against Violence educational program (ACT: http://actagainstviolence.apa.org/), which was created by the American Psychological Association’s Violence Prevention Office (2016). The intervention provides group-based parent education in nonviolent discipline, child development, anger management, and social problem-solving skills in school and community-based settings. Several evaluations have indicated that parents who participated in ACT reported using physical punishment significantly less often (e.g., spanking and hitting with an object) and using positive parenting practices more often (e.g., nurturing behavior) than parents in control groups (Knox et al. 2013). Another program targeting behavior change, the Chicago Parent Program, was developed in partnership with a parent advisory council that included AfricanAmerican and Latino parent perspectives. The intervention includes an 11-week program involving videotaped vignettes, facilitated parent groups, and weekly homework assignments. The program focused on a variety of positive parenting

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practices such as the value of praise and encouragement, the role of rewards for reducing challenging behavior, and various parenting strategies (i.e., ignore, distract, and time-out). In one experimental evaluation with low-income Latino and AfricanAmerican parents, those who participated in the program reported less frequent use of physical punishment and more frequent expressions of warmth toward their children compared to the control group (Gross et al. 2009). Pediatricians can potentially influence parents, as parents often seek advice from them and are likely to be receptive to their recommendations. Interventions designed for this setting can target parents directly or can target the pediatricians. Such settings provide nearly universal access to families, can be delivered at relatively low cost, and begin shortly after birth (Canfield et al. 2015). An intervention that targets parents in this setting is the Video Interaction Project (VIP). Parents in VIP view video recordings of their interaction with their child, recorded at each well-child visit (Canfield et al. 2015). After viewing the recordings, parents are coached to reflect on their behavior. Parents who participated in the VIP condition reported significantly less frequent use of physical punishment compared to parents in an informational mailing group or control group (Canfield et al. 2015). Other interventions have targeted health care settings more broadly. A “No Hit Zone,” a concept originally created by pediatrician Lolita McDavid, is an area that supports a “culture of safety” where “No adult shall hit another adult,” “No adult shall hit a child,” “No child shall hit an adult,” and “No child shall hit another child” (https://www.zeroabuseproject.org/thisisanohitzone/). No Hit Zones, which are typically identified by posters, target institutional staff as well as patrons. In a pre/post evaluative study design, hospital staff that received training about the No Hit Zone program and its goals had more negative attitudes about spanking and more positive attitudes about intervening when parents hit children, than did staff that received no training in the hospital (Gershoff et al. 2018a). This study demonstrated that NHZs are a feasible way to inform and train hospital staff in ways to intervene during incidents of parent-to-child hitting to promote a safe and healthy medical environment. The fact that a variety of approaches to intervention are successful – across a variety of targets, formats, and outcomes – supports the possibility of ending parental use of corporal punishment. Although these efforts are promising, further research is needed to identify the approaches that are most effective and the various program elements that are most important. In addition to changing attitudes and behaviors associated with corporal punishment, parents need to be taught alternative parenting strategies that are more effective.

Alternatives to Physical Discipline Many professional associations such as the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, the Centers for Disease Control and Prevention, and the American Professional Society on the Abuse of

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Children have issued policy statements both urging parents to avoid using physical punishment and directing professionals who work with parents to advise them to discipline their children with nonphysical techniques (Fortson et al. 2016; Sege and Siegel 2018). Most recently, the American Psychological Association (APA 2019) adopted its own resolution against physical discipline of children, recommending “that caregivers use alternative forms of discipline that are associated with more positive outcomes for children.” Child and family experts currently identify positive parenting, or positive discipline, as the preferred parenting approach (see Durrant 2013). Positive discipline respects the child as a learner and aims to help children succeed, give them information, and support their growth. It teaches appropriate behavior, self-regulation, and problem-solving skills, focusing on long-term outcomes rather than shortterm reduction of immediate misconduct, and attempts to keep children from harm while also enhancing developmentally appropriate skills (Durrant 2013; Sege and Siegel 2018). Consistent with a positive parenting approach, the APA resolution recommended the use of alternative forms of discipline such as “modeling orderly, predictable behavior, encouraging respectful communication, and teaching collaborative conflict resolution” (APA 2019). One important focus of positive discipline is on using positive reinforcement, rather than punishment, as a primary method of teaching acceptable behavior (Sege and Siegel 2018). Specific positive disciplinary strategies that are recommended by researchers and practitioners include redirecting misbehavior, teaching consequences of misbehavior, and withholding privileges at a developmentally appropriate level (AAP 1998; Scholer et al. 2010b; WebsterStratton et al. 2013). Although a full review of positive parenting approaches is beyond the scope of this chapter, several resources are available to parents and the general public. One such resources is Positive Discipline in Everyday Parenting (PDEP: Durrant 2013) available at www.positivedisciplinaeeveryday.com. PDEP was developed to enhance parent understanding and ability in a number of areas. It assists parents in understanding children’s rights to protection, dignity, and participation in their own learning. It helps change parents’ misattributions underlying parent–child conflict (e.g., a child may not be purposely inattentive, but rather may not be able developmentally to pay attention in a certain situation). It coaches parents to implement nonpunitive problem solving. Finally, it teaches parents about children’s emotional, social, and brain development during various developmental periods from infancy to adolescence. The Centers for Disease Control and Prevention have posted positive parenting tips on its Website (www.cdc.gov/ncbddd/childdevelopment/positiveparenting/ index.html). The American Academy of Pediatrics also provides information about positive parenting alternatives through their Websites including HealthyChildren (https://healthychildren.org/English/Pages/default.aspx) and Connected Kids: Safe, Strong, Secure (https://www.aap.org/en-us/advocacy-and-policy/aap-health-initia tives/Pages/Connected-Kids.aspx). As noted in the previous section, many interventions have demonstrated success in increasing such positive parenting behaviors and reducing the use of physical punishment.

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The Worldwide Movement to End Corporal Punishment In 1979, Sweden became the first country to prohibit corporal punishment. The law, drafted from a human rights perspective, reads: “Children are to be treated with respect for their person and individuality and may not be subjected to physical discipline or other abusive behavior” (Leviner and Sardiello 2019, p. 150). The ban was innovative and represented a “paradigm shift in the view on children having the same rights as adults” (Leviner and Sardiello 2019, p. 145). The Swedish government never had any intention of actually enforcing the law. It was always intended to be pedagogical in focus; an attempt to change attitudes. All indications are that it was quite effective in doing just that. In 1979 corporal punishment was widely accepted and practiced in Sweden, but today over 90% of Swedish parents believe that even mild forms of physical punishment are wrong (Leviner and Sardiello 2019). And, as we noted above, very few parents in Sweden hit their children. The idea that children have the right not to be hit gained international momentum and attention in 1989 when the General Assembly of the United Nations unanimously adopted the United Nations Convention on the Rights of the Child (CRC). Article 19 specifically acknowledges the child’s rights within the family, declaring that “State Parties shall take all appropriate legislative, administrative, social and educational measures to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse, while in the care of parent(s), legal guardian (s) or any other person who has the care of the child.” Importantly, Article 19, while urging states to protect children from “physical and mental violence,” does not specifically mention spanking or corporal punishment or the physical punishment of children. This clarification came in 2006, when the Committee on the Rights of the Child, which is responsible for implementing the CRC, issued General Comment #8: “The Committee is issuing this general comment to highlight the obligation of all States to move quickly to prohibit and eliminate all corporal punishment and all other cruel or degrading forms of punishment of children and to outline the legislative and other awareness-raising and educational measures that States must take” (UN Committee on the Rights of the Child, General Comment No. 8 2006, p. 3). The various statements from the United Nations are striking and direct: • Corporal punishment “violates children’s right to respect for their human dignity and physical integrity” (Lenihan 2019, p. 22). • Children are human beings and “must have their rights protected in the same was as are the rights of adults” (Lenihan 2019, p. 22). • Corporal punishment is a violation of their “physical integrity and human dignity therefore cannot be justified under any circumstances” (Lenihan 2019, p. 22). The CRC has been ratified by more countries than any human rights treaty in history and it has inspired governments to value and invest in the health and well-

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being of children (UNICEF 2019). Fifty-six countries now prohibit corporal punishment in all settings, including in the home, and 56 additional countries are “committed to reforming their laws” to achieve prohibition (Global Initiative to End all Corporal Punishment of Children 2019). As mentioned above, the CRC is the most ratified human rights treaty in history; 196 of the 197 U.N. member states have ratified the treaty. The lone holdout is The United States. Why the reluctance on the part of the United States? For some, especially political and religious conservatives, there is a concern that the CRC would limit parental “freedoms” and “rights” (Human Rights Watch 2014). For example, would the CRC’s statements on a child’s right to an education limit the “parental right” to homeschool a child? Would the CRC’s statements on a child’s right to live in a violence-free home lead to laws against spanking? These and other concerns are articulated in the following statement from the Family Research Council (FRC), a conservative advocacy organization. The statement is entitled “Parental Rights” and reads: FRC believes that both the responsibility and the authority for raising children rest primarily with their biological or adoptive parents. Government should empower parents to control the upbringing of their children and minimize its interference with the exercise of parental authority, except in cases of demonstrable abuse or neglect. Specifically, public policy should protect the right and maximize the power of parents to choose the form of education they wish for their children, be it public schools, secular or religious private schools, or home schooling. Public schools should avoid undermining parental authority or interfering with transmission of parental values to their children. Medical procedures should not be performed on minors without parental consent, except in cases of medical emergency or public health necessity. The right of parents to impose necessary discipline, including spanking, upon their children should not be infringed. (Parental Rights 2019)

It is worth noting the number of times this brief statement references the “rights,” “authority,” “values,” or “power” of parents, without once mentioning the rights of children. Treaty ratification in the United States requires a two-thirds vote in the Senate. Given the current political climate, it is hard to imagine ratification any time soon. Key Points • Throughout much of human history, corporal punishment, defined as the physical punishment of children for disciplinary purposes, has been common. • The discovery of childhood during the last several hundred years, and the increasing power of the child protection movement, means that, arguably, children are more valued today than at any time in human history. • Despite the increasing awareness of the value of children, corporal punishment remains the norm. Worldwide estimates are that 60% of children experience mild physical punishment each month, and 20% are severely punished (UNICEF 2014). In the United States, where corporal punishment is especially common, an estimated 80% of parents have spanked their child at some point during their child’s life (Gershoff et al. 2012).

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• Years of empirical studies have led social scientists to conclude that spanking is unnecessary as a disciplinary technique and potentially harmful to children. This research has further contributed to the social movement to eliminate corporal punishment. • Intervention studies suggest that young adults and parents who are exposed to evidence on the harm and ineffectiveness of corporal punishment can effectively change attitudes and behaviors. • Many countries, including much of Western Europe, have criminalized corporal punishment. In the United States, where conservative Christians are especially to take literally Biblical statements on corporal punishment, corporal punishment remains the norm.

Summary and Conclusion A husband upset with his wife cannot hit her. A Marine sergeant upset with a private cannot hit him. A prison guard upset inmates cannot hit them. Many, in fact, would argue that it is unjust to hit dog (e.g., https://pethelpful.com/dogs/Why-HittingDogs-is-Unacceptable). But a mother, frustrated with a misbehaving child, has full legal authority in most countries in the world to hit the child. According to Saunders et al. (2019), language helps us draw a distinction between the frustrated husband and the frustrated mother. The angry husband “hits’ or “punches” his wife. He engages in an act of “violence.” The mother, on the other hand, “smacks,” or “swats, or “paddles,” or “spanks” the misbehaving son. Such euphemisms are often combined with minimizing adjectives such as “little” or “gentle” or “just” or “only” or “good.” Unlike the husband who hits his wife, we are told, a parent who hits a child isn’t really engaged in an act of violence. But it is important to remember that this minimizing language does not alter reality. All forms of corporal punishment are intended to cause pain or discomfort. Spanking is hitting. Spanking is an act of violence. Currently, there are no laws in the United States prohibiting corporal punishment in the home. In 19 states, corporal punishment is actually allowed in schools (Gershoff et al. 2019). However, it is possible to imagine a time, perhaps in the very near future, where this will not be the case. The percentage of the U.S. population endorsing physical punishment has declined slowly but steadily over the last 60 years. In the 1960s, the overwhelming majority (94%) of Americans were in favor of physical punishment (Straus and Mathur 1996). By 1986, according to the General Social Survey, the percentage of Americans who believed that children sometimes need a “good hard spanking” was 84%. In 2018, the percentage of adults agreeing with this statement dropped to 67% (Smith et al. 2018). The prevalence of physical punishment in the United States is also declining (Finkelhor et al. 2019). Children are powerless. They cannot speak for themselves. But they do have rights. And they most certainly have the right not to be hit. There is every reason to believe, furthermore, that efforts to increase knowledge about the rights of children will continue to impact attitudes and behaviors about corporal punishment

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(Gallitto et al. 2019; Smith 2016). It seems inevitable that one day children will be culturally and legally protected from all forms of physical punishment.

Cross-References ▶ An Introduction to Child and Youth Maltreatment: Consequences and Considerations ▶ Child Physical Abuse: A Pathway to Comprehensive Prevention ▶ Corporal Punishment: From Ancient History to Global Progress ▶ Overview of Child Maltreatment

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Smith, T., Davern, M., Freese, J., & Morgan, S. L.. (2019). General social surveys, 1972–2018: Cumulative codebook (National Data Program for the Social Sciences Series, no. 25). Principal Investigator, Smith, T. W.; Co-Principal Investigators, Davern, M., Freese, J., & Morgan, S. L. Chicago: NORC, 3,758 pp., 28cm. Straus, M. A., & Mathur, A. K. (1996). Social change and change in approval of corporal punishment by parents from 1968 to 1992. In D. Frehsee, W. Horn, & K. Bussmann (Eds.), Family violence against children: A challenge for society (pp. 91–105). New York: Walter de Gruyter. The United Nations. (1989). Convention on the rights of the child. Treaty Series, 1577, 3. Trillingsgaard, T., & Sommer, D. (2018). Association between older maternal age, use of sanctions, and children’s socio-emotional development through 7, 11, and 15 years. European Journal of Developmental Psychology, 15(2), 141–155. UN Committee on the Rights of the Child (CRC), General Comment No. 8. (2006). The right of the child to protection from corporal punishment and other cruel or degrading forms of punishment (Arts. 19; 28, Para. 2; and 37, inter alia), 2 March 2007, CRC/C/GC/8. https://www.refworld. org/docid/460bc7772.html. Accessed 18 June 2019 UNICEF. (2014). Hidden in plain sight: A statistical analysis of violence against children. https:// data.unicef.org/resources/hidden-in-plain-sight-a-statistical-analysis-of-violence-against-children/. Accessed July 2019. UNICEF. (2019). What is the convention on the rights of the child? https://www.unicef.org/ childrights-convention/what-is-the-convention. Accessed July 2019. Vieth, V. I. (2014). From sticks to flowers: Guidelines for child protection professionals working with parents using scripture to justify corporal punishment. William Mitchell Law Review, 40(3), 3. Webster-Stratton, C., Reid, M. J., & Beauchaine, T. P. (2013). One-year follow-up of combined and child intervention for young children with ADHD. Journal of Clinical Child and Adolescent Psychology, 53, 251–261.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Health Promotion Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Universal Prevention Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Individual and Family Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Societal Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Primary Prevention Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Individual and Family Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Societal Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Secondary Prevention Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Individual and Family Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Societal Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tertiary Prevention Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Individual and Family Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Societal Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Societal Level Implementation on the Family Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Quaternary Prevention Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Individual Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Family Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . System-Level Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Disparities in CPA, Service Involvement, and Service Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Effectiveness of Prevention Programming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. H. J. Risser (*) · E. David Feinberg School of Medicine, Northwestern University, Chicago, IL, USA e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_252

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Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 630 Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 630 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 631

Abstract

This chapter provides an overview of the risk and protective factors associated with child physical abuse and a list of evidence-based interventions designed to target these factors and protect children from experiencing CPA. Universal, primary, secondary, tertiary, and quaternary prevention CPA interventions, such as home visiting programs and parent training models, are described in detail. They are broken down and organized by the levels of the socio-ecological model through which they operate, in order to affect change within the entire system (individual, family, community, societal levels). The chapter concludes with a discussion of the racial disparities and disproportionality of children of color within the child welfare system in the United States, specifically as it relates to child physical abuse cases. Keywords

Child physical abuse prevention · Primary prevention · Secondary prevention · Tertiary prevention · Quaternary prevention · Child abuse

Introduction Child physical abuse (CPA) is a pervasive public health concern, with as many as 25% of all adults worldwide reporting having been physically abused as children (World Health Organization [WHO] n.d.). The estimated economic burden of child maltreatment based on substantiated incident cases in 2015 was $428 billion annually (Peterson et al. 2018). Furthermore, the lifetime per victim cost of nonfatal and fatal child maltreatment was $830,928 and $16.6 million, respectively (Peterson et al. 2018). As Cross and Risser explain elsewhere in this handbook (▶ Chap. 72, “Child Welfare System: Structure, Functions, and Best Practices”), child protective services (CPS) is not able to independently meet the needs of children experiencing abuse. CPS must leverage other systems to adequately protect children. One way to accomplish this is to invest in a comprehensive, public health approach to CPA prevention (Durrant et al. 2009; Risser et al. 2019). A promising approach to conceptualizing comprehensive prevention is to combine Bronfrenbrenner’s ecological model with a vertical stepped care model of prevention (e.g., Glassgow et al. 2018) (Fig. 1). Thus, all layers of the social ecology can benefit from all levels of prevention. While different taxonomies of prevention are beyond the scope of this chapter, there is a benefit to using aspects of multiple taxonomies to specify prevention targets and activities. We propose that a comprehensive model of CPA prevention must contain elements of health promotion and universal prevention in addition to primary, secondary, tertiary, and quaternary prevention (Risser et al. 2019). Health promotion

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Fig. 1 Ecological Stepped Care Approach to Prevention

empowers people to achieve optimal physical and mental health by increasing access to high-quality information, services, and supports. Universal prevention provides CPA prevention information, services, and supports to an entire population, regardless of the presence of any risk factors for CPA. Primary prevention strategies aim to prevent CPA risk factors and promote protective factors that inhibit CPA. Secondary, or selective, prevention strategies aim to reduce the probability of abuse among parents who have risk factors of CPA. Tertiary, or targeted, prevention strategies aim to reduce the recurrence of CPA, reduce injury, and prevent additional CPA in families in which it has already occurred. Quaternary prevention strategies aim to prevent iatrogenic effects of CPA interventions such as out-of-home placements.

Mental Health Promotion Strategies Child health promotion strategies seek to optimize the healthy development of children and adolescents and prevent the burden of disease throughout the life course. From a population health perspective, these different strategies are most effective when coordinated and implemented together, to intervene at multiple points of the socio-ecological system: targeting behavior change not only among children and their parents but also at the institutional, community, and policy level (Korin 2016). Mental health promotion strategies could include traditional health promotion strategies that impact mental health (e.g., sleep and nutrition) as well as specific mental health

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promotion strategies like social emotional learning and supports, be kind campaigns, and emotion regulation strategies like mindfulness. Some examples of general health promotion strategies include media communications, such as commercials or public advertisements, health education and family support programs, changes in school policies regarding physical education and nutrition, community capacity building, and structural changes to the environment to facilitate healthy behaviors and mental health. While a full discussion of health promotion strategies to prevent CPA is beyond this chapter, it is important for parents and policy makers to understand that the importance of what to do to promote positive parenting behavior in addition to preventing ineffective and unsafe behavior that could lead to CPA.

Universal Prevention Strategies Universal prevention strategies provide CPA prevention information, services, and supports at the population level, regardless of the presence of any risk factors for CPA. Some existing universal CPA prevention strategies at the individual and family level include anticipatory guidance provided at well-child pediatric primary care visits, parenting education, and family support programs. Existing strategies at the community level include community capacity building and structural changes to the built environment, school programming fostering anti-bullying, and social emotional development. Some existing strategies at the societal level include highquality childcare and the public health system infrastructure.

Individual and Family Level Anticipatory guidance is proactive counseling provided to the parent(s) by a child’s primary care physician at every well-child visit. Anticipatory guidance provides information about physical, emotional, psychological, and developmental changes relevant to the child’s age to promote healthy development. Pediatricians provide education regarding a variety of developmental milestones relevant to the child’s situation (e.g., Dosman and Andrews 2012). The American Academy of Pediatrics has created a system of anticipatory guidance called Bright Futures that includes the schedule for distributing content that is recommended for each pediatric visit based on the child’s age (American Academy of Pediatrics n.d.). There is also some evidence to suggest that a brief intervention in primary care to promote nonphysical discipline strategies could reduce positive attitudes toward physical punishment (Chavis et al. 2013).

Community Level The Pyramid Model for Promoting Young Children’s Social Emotional Competence (Pyramid Model) is a multitiered framework designed to organize research practices and interventions that seek to improve young children’s (ages 0–5 years) social,

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emotional, and behavioral health outcomes (Fox and Hemmeter 2014). The lowest level of the pyramid model focuses on universal supports, which includes two key components to support children’s social and emotional skills: (1) high-quality environments (in the classroom and in the home) and (2) nurturing and responsive relationships. Strategies to achieve these competencies include supporting children’s play, specific praise and encouragement, structured play centers and schedules, and engaging activities with clear rules (Fox and Hemmeter 2014). The two higher tiers of the Pyramid Model focus on increased social emotional supports for children at risk of challenging behavior (secondary prevention) and individualized intensive interventions for children with persistent behavioral challenges (tertiary prevention) (Fox and Hemmeter 2014). Similarly, the Collaborative for Academic, Social, and Emotional Learning (CASEL) targets classrooms, schools, homes, and communities and provides guides and resources to support the adoption and implementation of social and emotional learning (SEL) programs across the schoolwide system. CASEL’s SEL framework promotes competencies for children in the domains of self-awareness, self-management, responsible decision-making, relationship skills, and social awareness (CASEL 2019). These two programs both provide universal support for children across settings, in order to promote healthy development and prevent risk factors for child maltreatment and abuse.

Societal Level An existing universal prevention strategy at the societal level is the US public health system infrastructure. The public health infrastructure includes the US Department of Health and Human Services (USDHHS), the principal federal agency tasked with protecting health and providing human services. Agencies such as the Administration for Children and Families (ACF) and Departments of Public Health operate at both the federal and the state level. Departments of Public Health also operate on regional levels within states. These agencies provide funding and human services as well as provide recommendations and policy guidance. Policies such as the Affordable Care Act represent societal level universal prevention strategies that ensure people have access to health care and behavioral health.

Primary Prevention Strategies Primary prevention strategies aim to reduce CPA risk factors and promote protective factors that inhibit CPA. Risk and protective factors can occur on an individual, family, community, or societal level. Risk factors at the individual level include parental mental health or substance use issues, unrealistic expectations for the child’s developmental level, positive attitudes toward physical discipline, and parental stress. Protective factors at the individual level include knowledge of child development and empathetic responding. Risk factors at the family level can include poor

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parent-child relationship, coercive parenting patterns, difficult child behavior, family disorganization, social isolation, and family violence. Protective factors at the family level can include secure attachment relationships, relationship routines and parentchild synchrony (dyadic interactions characterized as being extended, nonnegative, and connected), financial stability, safe housing, and social support (Harrist et al. 1994; Barber et al. 2001). Risk factors at the community level can include community violence, low neighborhood social cohesion (mistrust) and neighborhood divestment (lack of resources), and disorder (trash, vandalism). Protective factors at the community level include community resources for families (social support and social networks through schools, churches, and other organizations) and positive social norms that support a healthy and safe environment for families and children. Risk factors at the societal level include societal health and social disparities and social policies that contribute to disparities and structural (physical, legal, and economic) barriers to high-quality services. Protective factors at the societal level include access to health and social services, adequate housing, and economic supports.

Individual and Family Level Parent training is one type of intervention format used to target parents’ skills, knowledge, belief in physical/corporal punishment, and self-efficacy, in order to promote positive parenting practices and thereby protect against CPA. Brief trainings within the community, pediatrician’s office, or early home visitation by a nurse, social worker, or paraprofessional are common methods for delivering parent training interventions. The Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) administered by the federal Health Resources and Services Administration (HRSA) is a national effort that seeks to provide support and services to pregnant women and parents in order to prevent the development of some risk factors such as unrealistic expectations for child development and promote protective factors such as sensitive parental responding. MIECHV directly funds states, territories, and tribal entities to develop and implement their own programs based on common service delivery models, such as Healthy Families America, Nurse-Family Partnership, and SafeCare, all of which are described in further detail below (HRSA 2020). The program supports interventions promoting child health and development by health, social services, and child development professionals in the context of home visiting. It also supports the use of home visiting to teach positive parenting practices to prevent child abuse and neglect. In the Nurse-Family Partnership (NFP) program, public health nurses visit young, first time pregnant women and provide them with support, from pregnancy through their child’s second birthday. This program seeks to improve pregnancy outcomes, enhance parenting skills, and support the child’s health and development. Originally developed in the 1970s, it is now one of the most well-developed home visitation programs in the United States. Multiple randomized control trials (RCTs) and long-

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term follow-up studies have validated its positive effects on child health outcomes (Nurse-Family Partnership n.d.). One evaluation of the NFP revealed a 48% reduction in child abuse and neglect discovered at a 15-year follow-up among families who had received the intervention (Howard and Brooks-Gunn 2009). Triple P-Positive Parenting Program (Triple P) also started as an individualized home visiting program but has since grown to be a population-level, multitiered intervention. It is designed to strengthen families’ protective factors (knowledge, attitudes, and skills) while reducing the risk of child maltreatment by helping improve parents’ self-regulatory processes (Sanders et al. 2003). This intervention is unique in that the different tiers of the programs all reach a different population based on how intense children’s needs are. Level 1 of Triple-P is a universal mediabased information campaign on general parenting issues that seeks to promote awareness and normalization of participation in parenting programs. Levels 2–3 target parents with specific parenting concerns and include parenting seminars and brief consultations to normalize parenting interventions and offer skills training. Levels 4 and 5 add on to the interventions in previous levels by including training on more specific, targeted behaviors and parental concerns (it also qualifies as a secondary prevention program) (Sanders et al. 2003). Triple P includes curricula targeting five different developmental periods, from infancy to adolescence, and can be implemented in a variety of settings by different types of service providers (Prinz et al. 2009; Sanders et al. 2003). Prinz et al. (2009) randomly assigned 18 counties in the United States to receive either Triple P or services as usual. Counties with Triple P had significantly lower rates of substantiated cases of child maltreatment, childout-of-home-placements, and hospitalizations/ER visits for maltreatment injuries in the treatment counties (Prinz et al. 2009).

Community Level Neighborhoods with higher levels of positive social processes (collective efficacy, intergenerational closure, neighborhood social networks) and lower levels of physical and social disorder have been found to have lower rates of child maltreatment (Molnar et al. 2016). Social and cultural norms that condone or are indifferent to acts of violence can also influence individual-level attitudes, beliefs, and behaviors related to child physical abuse. Interventions targeting these modifiable risk factors within neighborhoods and communities to prevent the occurrence of child physical abuse include capacity building and mobilization efforts, as well as social marketing campaigns. Strong Communities for Children is one such comprehensive capacity building program geared toward child protection. The original program was implemented across neighborhoods in South Carolina, in which entire communities were mobilized in a large-scale effort to change social norms and other social processes within the community to prevent child abuse and maltreatment. Neighborliness, feelings of inclusion within the community, collective efficacy, and action were all targeted as community norms of interest. The program’s strategy involved using community

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outreach workers to drive grassroots level action to foster relationships between families and institutions in the community, in order to promote the message that children and parents are “noticed and cared for” by others in the community. These outreach workers also generated resources to meet families’ material needs, in addition to organizing the provision of family activities through existing community institutions. The Strong Communities program yielded positive changes in community social norms when compared with matched communities over time (Melton 2014). No Hit Zones (NHZ) are a primary prevention strategy that can help change social norms that support corporal punishment, which is a key risk factor for child maltreatment. When an organization adopts NHZ, it amends its policies to explicitly state that “no forms of hitting will be tolerated, including parents hitting their children” (Gershoff 2020). This policy is rooted in the theory of bystander intervention. As such, a key component of the policy includes training organization staff on how to identify a situation in which a parent might hit their child, helping them to feel a responsibility to intervene in such a situation and teaching them the knowledge and skills to intervene effectively (Gershoff 2020). An outcome evaluation of a hospital-wide NHZ intervention revealed that 10 months post-implementation, hospital staff felt less support for spanking and felt that their coworkers also felt less support for spanking, than they did prior to the intervention (Gershoff et al. 2018). The evaluation also revealed that parents’ perception that their children’s pediatricians supported spanking decreased post-intervention (Gershoff et al. 2018). Both of these results lend support for NHZ as a means to change attitudes and social norms toward physical punishment. In addition to negative social processes, community violence is another risk factor associated with high rates of child physical abuse. Community violence prevention programs, such as Communities That Care (CTC) seek to prevent violence in communities before it begins. CTC was developed by the University of Washington, and similar to Strong Communities, operates at a grassroots level to build community coalitions and an advisory board to assess the unique risk and protective factors for violence within a specific community. After the assessment, CTC trainers work with community members to develop specific, measurable goals to promote youth’s social development, strengthen protective factors, and implement evidencebased programs that target predicted child and adolescent health and behavioral problems within the community. Results of the program show that when compared to a matched sample of students, students from CTC communities had fewer health and behavior problems, including a lower likelihood of initiating delinquent behavior and initiating use of alcohol or cigarettes, and lower odds of engaging in violent behavior within the past year (University of Washington n.d.). Large-scale social marketing through educational media campaigns can also change individual and community-level social norms and behaviors regarding child physical abuse. One such campaign would be the first level of the aforementioned Triple P program, which is a multimedia campaign that targets all parents, in order to increase awareness and adoption of positive parenting practices with the intent of normalizing such behaviors within the community. It includes a range of

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materials distributed through various channels, including brochures, posters, newspaper columns, and billboards (Triple n.d.).

Societal Level Flexible and family-friendly work policies, including livable wages, paid leave, and consistent scheduling, are all policies that organizations and governments can implement to provide economic supports to families. A guaranteed annual income has been shown to lead to decreases in low levels of education and mental health problems, which are two risk factors associated with child abuse and neglect (Fortson et al. 2016). Various studies have shown that paid leave, in the form of sick days, maternity leave, and vacation, are associated with reductions in child hospitalizations for abusive head trauma and lower rates of parental depression and stress (Fortson et al. 2016). A consistent schedule in turn also allows parents to manage more consistent childcare services. Parents who work irregular schedules have been shown to experience greater work-family conflict and stress (Fortson et al. 2016). Head Start programming is another strategy that is implemented on the societal level to promote school readiness in children from low-income families. State legislative policy to reduce or ban corporal punishment (CP) has also been suggested as a method to change social norms and acceptance of corporal punishment as a discipline technique. For example, Sweden has banned CP. Studies have shown that individuals who reported experiencing spanking, a mild form of CP, during childhood, were 60 times more likely than their counterparts to also report having experienced physical abuse as children (Fréchette et al. 2015). While some States in the United States have banned the use of corporal punishment in childserving settings such as schools and juvenile detention facilities, many states have not. Despite many organizations supporting a complete ban on physical punishment, including the American Academy of Pediatrics, the United States has not banned CP in some child-serving settings or within the home (Fortson et al. 2016).

Secondary Prevention Strategies Secondary prevention strategies focus on reducing risk within populations that already have one or more risk factors associated with physical abuse, such as young parental age, parental substance abuse, or parental mental health concerns (Child Welfare Information Gateway [CWIG] n.d.). Home visiting programs similar to those described above are common secondary prevention interventions that target the individual and family-level risk factors for child physical abuse. Safe From the Start (SFS) is another federal and state strategy for treating young children who have been exposed to violence and preventing additional exposure. SFS is also implemented on a state level. In Illinois, for example, the Illinois Criminal Justice Information Authority funds between 9 and 12 sites to provide community-based mental health treatment to children and families exposed to violence, community

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support, and prevention activities (e.g., Schewe et al. 2013; Risser and Schewe 2013). The California Evidence-Based Clearinghouse for Child Welfare (CEBC) is a resource designed to promote the implementation of EBTs for children and families in the child welfare system. The CEBC uses the Scientific Rating Scale to indicate the extent to which the intervention has evidence supporting its effectiveness. The CEBC assigns a rating to each intervention that it reviews. Lower ratings indicate a greater level of empirical evidence supporting the intervention’s effectiveness. The Scientific Rating Scale ratings range from 1 (well-supported by research evidence) to 5 (concerning practice) with a 6th category for interventions that are unable to be rated (California Evidence-Based Clearinghouse for Child Welfare n.d.). The CEBC ratings are as follows: (1) well-supported by research evidence; (2) supported by research evidence, (3) promising research evidence, (4) evidence fails to demonstrate effect, (5) concerning practice, and (6) not able to be rated (NR) on the CEBC Scientific Rating Scale. Psychotherapy models that are rated as 1 on the CEBC ratings can be considered EBTs.

Individual and Family Level SafeCare is one example of an evidence-based in-home intervention delivered to parents who are either at-risk or have been already been reported to CPS for child maltreatment. The overall goal of the SafeCare curriculum is to improve parenting skills and reduce future incidents of maltreatment. The curriculum includes three major components, addressing (1) the health of the child, (2) home safety, and (3) positive parent-child interactions (parenting skills) (Georgia State University n.d.). This last module specifically targets risk factors related to neglect and physical abuse. Over 60 studies over the past 30 years support the effectiveness of SafeCare, including a statewide cluster RCT, in which SafeCare’s effectiveness was compared to usual home-based services (Chaffin et al. 2012). Recidivism outcomes were promising, for example, families who received the SafeCare intervention had a rate of child maltreatment that was approximately 26% lower than families receiving usual services (Chaffin et al. 2012). The Chicago Parent Program was designed to target the parenting needs of racially and ethnically diverse families with young children, living in low-income communities (Breitenstein et al. 2020). The 12-session curriculum is based on social learning theory and attachment theory. Parents watch video recordings of short parenting vignettes and practice parenting skills through role plays. CPP staff also interact with parents to encourage them to develop strategies for supporting a nurturing environment at home. Content specifically related to the reduction of spanking and physical punishment is included to reduce the risk of CPA and is presented through discussions that offer alternative strategies for discipline in a culturally competent manner. Two cluster RCTs have shown that the Chicago Parent Program yielded significant improvement in parenting self-

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efficacy, a decline in physical punishment, and more consistent discipline (Breitenstein et al. 2020). Healthy Families America (HFA) (CEBC 2019) is a second home visiting program that targets families at-risk for child abuse and neglect due to a history of trauma, mental health issues, and/or substance abuse issues. It is theoretically rooted in attachment theory, and the principles of trauma-informed care and services in the program are initiated either prenatally or at birth, until the child reaches 3–5 years of age (CEBC 2020). Primary components of HFA include screening and assessment for at risk families, home visiting services, and screenings and assessments of parent-child interactions, child development, and maternal depression (US Department of Health and Human Services 2018). It has been rated by the CEBC as a level 1 intervention for child-well-being and level 4 for prevention of abuse and neglect.

Community Level Media campaigns targeting people susceptible to acts of child abuse and maltreatment are also a type of secondary prevention strategy that can lead to changes in individual and community level social norms, attitudes, knowledge, and risky behaviors. The Breaking the Cycle campaign was part of a broad community-level intervention from the late 1990s implemented in New Zealand, which used television, radio, print media, phone lines, and other resources to increase parents’ awareness and knowledge about child emotional and physical abuse. The campaign used the transtheoretical model stages of change theory in order to influence parents to engage in non-abusive behavior (Stannard et al. 1998). A survey evaluating the results of the campaign revealed that up to 44% of the population contemplated changing their behavior as a result of the campaign, and up to 16% actually reported changing their behavior, which in this case referred to acts of child emotional abuse (Stannard et al. 1998).

Societal Level Policy level interventions to provide economic supports for children and families have the potential to have the most significant impact on lowering the risk for child abuse and neglect. By strengthening household financial security, parents can more easily provide for their child’s basic needs and access childcare services. This results in improved parent mental health due to decreased stress (Fortson et al. 2016). The Earned Income Tax Credits (EITC) are federal tax credits refunded to low- and moderate-income families through their tax returns (IRS 2020). They help reduce child poverty and reward low-income families for employment. The EITC have been found to have positive impacts on decreasing infant mortality, increasing health insurance coverage, promoting school performance, and reducing parental stress

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(Fortson et al. 2016). The Supplemental Nutrition Assistance Program (SNAP), colloquially known as “food stamps,” helps low-income families purchase food. As well as helping meet children’s basic nutritional needs, it helps reduce family and child poverty and the severity of food insecurity. Empirical evidence supports the benefits of SNAP, one study linking Medicaid children receiving SNAP or other nutrition benefits with fewer reports of child abuse and neglect than families not receiving the benefits (Fortson et al. 2016). States can apply grants from the US Housing and Urban Development toward the purchase of homes in low-poverty neighborhoods, which they can then rent to lowincome families at a lower cost. This allows families to relocate to safer, wellresourced communities and save money on rent. The US Department of Housing and Urban Development’s Moving to Opportunity (MTO) experiment in the 1990s revealed that low-income families who received a housing voucher for low-poverty neighborhoods experienced less psychological distress and depression, and their children were more likely to attend college and earn a higher income (Ludwig et al. 2012; Fortson et al. 2016). Subsidized child care is another type of economic support that increase parental capacity by aiding parents in choosing higher quality care for their children, thus leading to a higher likelihood for those children to be cared for in a safe, nurturing environment (Fortson et al. 2016). The Illinois Action for Children Child Care Assistance Program (CCAP) is one such state program through which qualifying families can receive financial support for childcare. The IL Action for Children also offers an array of programs and services through initiatives such as the Teen Parent Project, Prevention Initiative (for at risk teen mothers and their children), Family Engagement Training, and early learning programs for young children.

Tertiary Prevention Strategies Tertiary, or targeted, prevention strategies aim to prevent additional CPA or reduce the impact of CPA. Existing tertiary strategies include a variety of therapeutic interventions. Some interventions focus primarily on reducing the impact of CPA by addressing symptoms of trauma and other emotional and behavioral effects on the child. Some interventions primarily focus on changing parent behavior to prevent additional CPA. Information about the interventions, the populations for which they are suited, and the effectiveness in improving targeted symptoms and behaviors are available online from the California Evidence-Based Clearinghouse for Child Welfare (2020). For interventions and practices specifically designed for children who have experienced trauma, see The National Child Traumatic Stress Network (nctsn.org). Several therapeutic interventions have been designed to treat child victims of physical abuse and their families. Evidence-based treatments (EBTs) have demonstrated statistical and clinical significance in reducing symptoms in children who have experienced physical abuse. For reviews of interventions for childhood

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symptoms of trauma, see The National Childhood Traumatic Stress Network (NCTSN) ( n.d.) and Vanderzee et al. (2019).

Individual and Family Level Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Trauma focused cognitive behavioral therapy (TF-CBT) was designed to treat children aged 3–21 years who have a history of trauma exposure (Kliethermes et al. 2017). The goal of TFCBT is to reduce trauma-related symptoms. The program components include psycho-education and skill development such as relaxation skills, affect regulation, cognitive coping, trauma processing, and in vivo exposures. Treatment can include both individual and parent-child sessions. The treatment targets are symptoms of trauma, depression, anxiety, grief, and/or shame related to their traumatic experience. On the CEBC ratings, TF-CBT has been rated level 1 (CEBC 2020). Parent-Child Interaction Therapy (PCIT). PCIT was designed to treat issues that interfere with parent-child relationships in children aged 2–7 years old and their parents. Treatment goals include decreasing child externalizing behaviors, increasing child social skills, and improving the parent-child relationship. Treatment components include skill development and behavior management skills during playbased coaching sessions. Treatment targets include increasing child compliance, increasing parent use of praise, effective commands, and appropriate consequences for noncompliance, and decreasing parent use of coercive parenting behaviors. While PCIT has a CEBC rating of 1 for disruptive behavior and parent training for disruptive behavior, it has not been rated for use of reducing additional CPA. However, a randomized clinical trial demonstrated significantly lower rates of rereport to CPS in the PCIT group (19%), relative to a community-based parenting group (49%) (Chaffin et al. 2004). Child-Parent Psychotherapy (CPP). CPP was designed to treat children aged 0–5 years who have been exposed to a traumatic event or events (Lieberman et al. 2005; Reyes et al. 2017). The child is seen with his or her primary caregiver. Goals of the intervention include examining how previous and current experiences, behavior, and context impact the parent-child relationship and the child’s development. Treatment targets include strengthening the parent-child relationship and ameliorating caregivers’ and children’s maladaptive representations of themselves and each other and promoting positive interactions and behavior that support the child and the parentchild relationship. CPP has been rated level 2 on the CEBC rating scale (CEBC 2020). Multisystemic Therapy for Child Abuse and Neglect (MST-CAN; Swenson et al. 2010). MST-CAN was designed to treat children aged 6–17 years old, and their families recently reported to child protective services due to the physical abuse and/ or neglect. The family may be intact or the child may be placed in foster care. Goals include reducing physical abuse, out-of-home placement, and family reunification for children in out-of-home placement, improving noncoercive parenting, and improving family functioning and social support. Treatment components include

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intensive services, 24/7 services for families, parent training, caregiver mental health and substance abuse, anger management, and family communication training. Treatment targets include youth aggression, anxiety and trauma symptoms, substance abuse, difficulty managing anger, safety risks, difficulties with family problem solving, negative family communication, parental physical and psychological aggression, social support, and other dysfunctional behavior. MST-CAN has been rated level 2 on the CEBC rating scale (CEBC 2020). Child-Centered Play Therapy (CCPT). Child-centered play therapy (CCPT) was designed to treat children aged 3–10 years who are experiencing social-emotional and behavioral problems (e.g., Lin and Bratton 2015; VanFleet et al. 2011). The child is seen individually usually for 16–20 sessions. The goal of CCPT is to promote more positive and integrated self-concept. Components of CCPT include accessing child’s feelings through play and developing a strong therapeutic relationship, reflection, empathic response and therapeutic limit setting. CCPT targets include improved coping, self-reliance, and sense of control. CCPT has been rated level 3 on the CEBC rating scale (CEBC 2020). Combined Parent-Child Cognitive Behavioral Therapy (CPC-CBT) (Runyon et al. 2009). CPC-CBT was designed for parents of children aged 3–17 years old in which parents use coercive parenting behaviors. Treatment goals include enhancing parent-child relationship, healthy coping, and behavior change. Treatment components include psychoeducation, motivational interviewing, addressing trauma history, adaptive coping, anger management, relaxation, interpersonal effectiveness, problem solving, affect regulation, behavior management, safety planning, trauma processing, and parent training. Treatment targets include decreasing coercive parenting behavior and child internalizing and externalizing and trauma symptoms. CPC-CBT can be delivered in individual family sessions or group family sessions. In the group sessions, it is recommended to have 4–5 families involved and that may include multiple caregivers and multiple children. All topic areas of CPC-CBT (interventions for abusive behavior, parent training programs that address child abuse, prevention of child abuse and neglect, and child and adolescent trauma treatment) have been rated level 3 on the CEBC rating scale (CEBC 2020). Alternatives for Families Cognitive-Behavioral Therapy (AF-CBT). AF-CBT was designed to treat parents of children aged 5–17 years old, who are verbally or physically aggressive toward their children and children who experience traumarelated symptoms as a result of parent behavior. Treatment goals include improving parent-child relationships, strengthening effective parenting practices, enhancing child coping and social skills, increasing safety, reducing coercive and aggressive behaviors, and decreasing risk of additional child physical abuse. Treatment components include a multi-informant assessment, motivational interviewing, functional behavioral analysis, psychoeducation, affect regulation, parent training, behavior management, cognitive restructuring, trauma processing, social skill development, assertiveness training, problem solving, and effective communication. Materials such as handouts, examples, and outcome measures are integrated into the treatment, and clinicians tailor aspects of the treatment to the family’s specific strengths and challenges. Treatment targets include increasing interpersonal effectiveness,

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decreasing aggressive and hostile behavior, reducing trauma-related symptoms, increase affect regulation, and use of effective noncoercive parenting behavior. AF-CBT is designed to be delivered in three phases. The child is typically seen individually for the first and second phases, and the parent and child participate together in the third phase. AF-CBT has been has been assigned a level 3 on the CEBC rating scale (CEBC 2020). Attention, Regulation, and Competency (ARC). The ARC framework was designed to treat children and youth aged 2–21 years with complex trauma, particularly attachment-related traumas such as child abuse and neglect (Blaustein and Kinniburgh 2018; NCTSN n.d.). The intervention usually involves the parent-child dyad. The goals of the ARC framework include improving parent-child attachment, affect regulation, and children’s resilience and strengths. Treatment components include psychoeducation, skill development, and behavioral change. Treatment targets include increasing predictability and a sense of safety, improving the parent-child relationship, and increasing adaptive affect regulation. The ARC framework has been rated NR on the CEBC ratings with a high level of child welfare relevance (CEBC 2020). Project Support should be capitalized is another intervention designed to reduce incidents of child maltreatment in families reported to CPS for allegations of physical abuse and neglect (Jouriles et al. 2010). The intervention includes two key components. The first is a hands-on, intensive child management skills training designed for mothers, which covers skills such as listening to their child, providing contingent praise, and participating in attentive play (Jouriles et al. 2010). This inhome training incorporates didactic teaching and opportunities for practice with feedback, in order to reduce coercive parent-child interactions. The second key component of the program involves providing instrumental and emotional support to mothers in order to reduce their psychological distress. The curriculum is delivered by a therapist in weekly sessions for up to 8 months. In comparison with services as usual delivered by CPS caseworkers, mothers in the project support condition demonstrated greater decreases in their perceived inability to manage their children’s behavior and decreases in self-reported harsh parenting. In addition, only 6% of Project support families had a re-referral to CPS compared to 28% of families in the services as usual branch (Jouriles et al. 2010).

Community Level One existing community-level tertiary prevention strategy is wraparound service provision (e.g., Yohannan et al. 2017). Wraparound is a team-based, planning and implementation process designed for families of children aged 4–17 years old with severe emotional and behavioral problems. Wraparound was designed for children and families that have complex needs, are often involved in several child and familyserving systems such as CPS and juvenile justice, and are either in or at risk of being placed in, out-of-home placement (quaternary prevention). The goals of wraparound are to stabilize crises and develop and implement a care plan and safety/crisis plans.

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Wraparound components include developing action steps and addressing logistics related to care plan implementation, tracking progress, evaluating success, updating plan and strategies as needed, maintaining team cohesion, and developing a transition and termination plan. Treatment targets include maintaining children in their homes and communities, improving family function across all life domains, and decreasing out-of-home placements. Two wraparound topic areas (behavioral management programs for adolescents in child welfare, placement stabilization programs) have been rated as a 3 on the CEBC rating system (CEBC 2020).

Societal Level Child protective services (CPS) or child welfare services (CWS) are state-level systems that are the principal agency responsible for tertiary prevention (see ▶ Chap. 72, “Child Welfare System: Structure, Functions, and Best Practices”). CPS has a variety of services designed to prevent additional CPA. However, most of the CPS services are implemented on the family level. The Child Abuse Prevention and Treatment Act (CAPTA) and the CAPTA Reauthorization Act are examples of societal level policies that establish and maintain the Office on Child Abuse and Neglect and the National Clearinghouse of Information Related to Maltreatment. CAPTA provide States with funding and guidance regarding prevention, assessment, investigation, prosecution, and treatment. CAPTA also funds public, nonprofit, and tribal organizations to conduct demonstration programs. CAPTA also specifies the federal role in supporting research and data collection regarding the prevalence of child abuse, neglect, and CPS involvement.

Societal Level Implementation on the Family Level Intact services are provided to families in which the child remains in the home despite a substantiated instance of CPA. Intact services could include a wide variety of services that could include CPS caseworker case management, EBTs to reduce additional CPA, and other interventions targeting risk factors for CPA (e.g., parent substance abuse treatment). Intensive family preservation services are provided to intact families with a high level of risk and needs. Intensive family preservation services are provided by a mental health professional and typically involve more frequent and intensive service delivery. For example, a service array could include individual sessions, parent training, and family sessions within the same week. Some programs provide access to 24/7 professional support. Family stabilization programs are designed to ensure the safety and well-being of children in families that have been reported to CPS. In this chapter, programs implemented with families in which children have not yet been placed out of the home, we discuss them in the tertiary prevention section. For programs implemented with families in which children are returning from out-of-home placement, we discuss them in the quaternary prevention section. Some programs can be

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implemented as either tertiary or quaternary prevention. One program, Homebuilders ®, has been rated as level 2, three programs have been rated as level 3, and eight programs have not been able to be rated on the CEBC rating scale (CEBC 2020). Family group decision-making (FGDM) (CEBC 2017b) is one program which is targeted toward children who are abused and/or neglected and their family groups. The program emphasizes the importance of including not only children and their parents in the program’s treatment model but the entire family group, which consists of people connected to the child through extended kinship and other relationships. The family group works with a trained coordinator and CPA personnel to develop and implement plans to protect the safety, permanency, and well-being of the child. It is rated as a level 3 by the CEBC, indicating promising research evidence in support as a family stabilization programs, placement stabilization programs, and program that reduces racial disparity and disproportionality in child welfare programs (CEBC 2020). Sobriety Treatment and Recovery Teams (START) (CEBC 2017a) is another family stabilization program, which targets families with at least one child under 6 years of age in the child welfare system, and a parent with a reported substance use problem that places the child at risk. A few of the key components of START include families’ quick entry into START program (program takes only new cases within 30 days of CPS referral), family team meetings scheduled at key points in the program, addiction treatment and mental health services for parents, and full-time family mentors who attend home visits with an assigned CPS worker. It is scored at level 3 by the CEBC rating scale (CEBC 2020). Family-centered treatment (FCT) (CEBC 2018) is an intensive, homemvisiting program that aims to provide families with practical solutions to ensure family stability and functioning, when there is an imminent risk of disruption of the family unit. This can refer to the removal of the child from the home due to abuse/neglect or the child’s delinquent behavior or other stressors and circumstances. The program includes multiple phases, which seek to assess families’ goals and strengths, training and coaching the family in new skills, all to achieve a balance and level of functioning that reduces harm and increases coping and stability within the family. FCT targets families with children 0–17 years of ages involved in agencies related to either child welfare, mental health, substance abuse, developmental disabilities, juvenile justice, or crossover youth. It is scored at level 3 by the CEBC rating scale (CEBC 2020). Family preservation programs “not rated” by the CEBC on their scientific merits as of yet include Cultural Broker Program, Families First of Michigan, Foster Care Redesign, Functional Family Therapy Child Welfare (FFT-CW), Minority Youth and Family Initiative for African Americans (MYFI), Minority Youth and Family Initiative for American Indian/Alaskan Native Children (MYFI), Mockingbird Family Model (MFM), and the Parent Support Outreach Program (PSOP) (CEBC 2020). Supervised visitation may be court ordered if there is high risk for continued CPA. Supervised visitation typically involves visitation between the child(ren) and the previously abusive parent. The child(ren) may be living with the other parent, other family members, or in an out-of-home placement. Supervised visitation can occur

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within a family setting with another family member designated as the supervisor or at a community-based organization with a professional staff member of the organization supervising the visit. In some cases, visits can be supervised by a guardian ad litem, a person appointed by the court to determine what solutions would be in the best interests of the child. Out-of-home placements (discussed in Cross and Risser) can also serve to prevent future CPA by placing the child in a safe living arrangement away from abusive parents. This strategy is typically used when CPA has led to serious child injury, risk of CPA continues to be very high, or the child has serious health, mental health, or behavioral needs after experiencing CPA that cannot be managed in the home of the child’s biological parents. Termination of parental rights is a term that refers to the legal status of no longer being the child(ren)’s parent. The termination of parental rights is reserved for situations in which risk the child remains high, and it is unlikely that the child will be able to return to reside with his/her family of origin. In this case, in an effort to promote permanency (see Cross & Risser), CPS may seek to terminate parental rights so that the child may be eligible for adoption into another permanent family.

Quaternary Prevention Strategies Quaternary prevention strategies aim to prevent iatrogenic effects of CPA interventions such as out-of-home placements. The Family First Prevention Services Act (FFPSA) was signed into law in 2018. The FFPSA was designed to reform the funding for child welfare by setting parameters around how money through Title IVE and Title IV-B, of the Social Security Act could be spent. FFPSA was designed to emphasize prevention and early intervention and reduce out-of-home placements in congregate care. FFPSA was also designed to promote the use of evidence-based practices for children and families and improve the well-being of children already in foster care.

Individual Level Existing individual-level quaternary prevention strategies include many of the individual-level components of tertiary interventions listed above. The targets of these interventions at the quaternary level are often to ameliorate symptoms that children may develop in response to an out-of-home placement or dealing with the grief and loss of a biological parent or family of origin.

Family Level Existing family-level quaternary prevention strategies include a variety of programs for family of origin and foster parents.

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Families of Origin Homebuilders were designed to treat families of children aged 0–18 years old needing intensive services to return from out-of-home placements such as foster care or residential treatment including psychiatric and juvenile justice placements (CEBC 2020). Foster Families Trainings are designed to provide foster families with knowledge and tools for better understanding and responding to child(ren)’s needs (California Evidence-Based Clearing House for Child Welfare 2020). Some training includes general knowledge, and some have been assigned a CEBC rating that indicates the extent to which it is an EBT. KEEP (Keeping Foster and Kin Parents Supported and Trained; Price et al. 2019) was designed to train foster caregivers of children aged 4–12 years old. The goal of KEEP is to provide foster parents with tools to manage child (ren)’s emotional and behavioral problems. Treatment components include psychoeducation, behavior management training, affect regulation, setting effective limits, and stress management and are delivered in a 90-minute, weekly group setting. Treatment targets include decrease placement disruptions, increase effective parenting strategies, decrease child emotional and behavioral symptoms, and decrease parent stress. Three of the KEEP interventions (kinship caregiver support groups, placement stabilization programs, and resource parent programs) have been rated as a level 3 on the CEBC rating scale (CEBC 2020). Three adaptations for foster parents of adolescents, called KEEP SAFE (behavioral management programs for adolescents in child welfare, resource parent programs, and placement stabilization programs), have been rated as a level 2 on the CEBC rating scale (CEBC 2020).

System-Level Interventions Foster care redesign (FCR) was designed for ethnically diverse and minority children aged 0–17 years old and their families who are at risk of entering CPS. FCR was designed to address overrepresentation of minority populations in the child welfare system. It is an attempt to implement programmatic and organizational changes that prioritize prevention and diversion services over out-of-home placements (CEBC 2020). Components of the redesign include safety management services, in-home family-centered services, behavior change, an integrated practice team, and case management. Targets include reducing the number of children entering out-of-home care and reducing re-referral for child abuse and expedite reunification. FCR has been rated as NR (not able to be rated) on the CEBC rating scale (CEBC 2020).

Disparities in CPA, Service Involvement, and Service Delivery Dakil et al. (2011) examined child physical abuse disparities across ethnic groups to better understand the high prevalence of minorities within the child protection system. African Americans were found to have the highest rates of reported physical

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abuse cases, highest rates of substantiated physical abuse, and the highest rate of physical abuse related deaths in the United States, compared to whites, Latinos, Asian/Pacific Islanders, multiracial, and Native American children. Of the reported cases of physical abuse for each race/ethnicity, African American, Asian/Pacific Islander, and multiracial cases were more likely to be substantiated, compared to those of white children (Dakil et al. 2011). In addition, a greater percentage of reported physical abuse cases resulted in death within Native Americans, African Americans, and Asian/Pacific Islanders families. These disparities may indicate a need for addressing cultural bias and culturally tailored physical abuse prevention interventions. In addition to the disproportionate representation of minority children in the child protection system, disparities also exist in the types of CPS interventions which are provided and accessed by families. In Dakil et al.’s (2011) study, Latinx had much lower odds of being offered family preservation, adoption, foster care, and employment/educational services compared to Whites. African Americans, however, had higher odds of being offered educational/employment services, but lower odds of mental health and substance abuse services. There are multiple hypotheses that have been proposed as to why certain ethnic groups are more likely to receive certain types of services, including factors related to the family’s cultural preferences and caseworker biases in reporting and assessment (Dakil et al. 2011). It is also important to note that while families of color might be offered or referred to certain services more often than whites, they may not necessarily be receiving the services due to issues of accessibility and availability within the communities that they live (CWIG 2016). A study investigating the availability and proximity of child welfare services in predominantly Black and Latinx communities in three Texas cities revealed that despite the overrepresentation of minorities in the state welfare system, there was either no nearby services or no/lengthy public transportation to access needed services in 25% of the combined cities (Dorch et al. 2010). A lack of access to child welfare and parent education services has the potential to negatively impact families’ case plans and influence their subsequent interactions with CPS, in ways that would only serve to increase the disparities in the system and reduce the likelihood of family reunification (CWIG 2016).

Effectiveness of Prevention Programming While universal and primary prevention can have a significant impact on reducing CPA and a large return on investment, universal and primary prevention strategies suffer from a lack of rigorous empirical research and are often accompanied with significant implementation challenges. For programs that demonstrate null effects, it can be difficult to determine if the intervention is not effective or if there were problems with implementation or aspects of the evaluation design and protocol. For example, a statewide implementation of the Hawaii Healthy Start Program (HSP) assessed the intervention’s impact on preventing child abuse and neglect over a 3-year period (Duggan et al. 2004). HSP involves two phases: (1) screening

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and assessment to identify families at-risk for child maltreatment and (2) home visiting of families by trained paraprofessionals. The program model involves educating parents, modeling problem-solving skills, and providing instrumental support to help parents access services to support their family. Despite being the central purpose of the intervention, study results showed that HSP had very little program impact in regard to preventing child abuse and promoting nonviolent discipline, with HSP and control groups presenting similarly across most measures of abuse and neglect. Potential explanations to explain this result pointed to the fact that the needs of the families, many of whom had multiple, complex risks for abuse were not able to be addressed by the level of training of the paraprofessional (Duggan et al. 2004). Furthermore, paraprofessionals rarely referred parents to needed services in the community, suggesting an issue in program implementation (Duggan et al. 2004).

Key Points • A comprehensive public health approach to prevent child physical abuse (CPA) incorporates universal, primary, secondary, tertiary, and quaternary prevention strategies that intervene at multiple levels of the social ecology. • Mental health promotion strategies function to prevent CPA by supporting children’s positive health behaviors, socio-emotional learning, and overall wellbeing. • Universal prevention strategies operate at the population level to prevent CPA regardless of the presence of risk factors. • Examples of universal prevention strategies include anticipatory guidance, promoting children’s socio-emotional learning, and public health system infrastructure. • Primary prevention strategies reduce risk factors and promote protective factors against CPA. • Examples of primary prevention strategies include parent training and home visiting programs, capacity building programs for neighborhoods, and familyfriendly work policies. • Secondary prevention strategies target populations that already have one or more risk factors for CPA. • Secondary prevention interventions include home visiting programs, communitylevel campaigns to change high-risk behavior, financial and housing security, and subsidized childcare. • Tertiary, or targeted, prevention strategies include therapeutic interventions that address symptoms of trauma or other effects of CPA on the child, or change parent behavior to prevent the recurrence of CPA. • Examples of tertiary prevention strategies include evidence-based treatment, wraparound and family stabilization services, and child protective service infrastructure.

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• Quaternary prevention strategies aim to prevent iatrogenic effects of CPA interventions, such as out-of-home placements. • Examples of quaternary prevention strategies include evidence-based treatment, trauma-informed services, Family First Prevention Services Act, and CPS redesign. • There is a disproportionate representation of children of color within the child protection system. There are gaps in the types of CPS interventions which are provided to and accessed by families of color. We need to be cognizant of eliminating bias that contribute to harmful practices. • Universal and primary prevention interventions can suffer from implementation challenges that make it difficult to determine a program’s true effectiveness.

Summary and Conclusions The United States has established a comprehensive array of health promotion and CPA prevention resources, services, and policies. It has allocated funding to implement policies and provide services and resources (e.g., Fortson et al. 2016; U.S. Department of Health and Human Services 2016; Rudolph et al. 2018). The United States and its citizens are committed to CPA prevention. However, CPA continues to be a major public health concern. There are at least four ways that we could more effectively prevent CPA. First, we can fully align system-level policies and infrastructure with children’s needs for a safe and stable upbringing (Risser et al. 2019). While we discussed multiple policies and infrastructure that support children and families and are designed to prevent CPA, there are countless other opportunities to more effectively prevent CPA. Second, we can ensure ubiquitous access to effective CAN prevention resources and services for all families. This includes access to highquality, evidence-based services and financial support to facilitate healthy family function (Risser et al. 2019). Third, by promoting earlier health promotion and strength-based prevention services, perhaps we can reduce any stigma that may prevent caregivers from seeking support and accessing services. Removing the stigma associated with child welfare services as something to remediate parenting could pave the way for child welfare to more proactively partner with families. This way we can support families in feeling entitled to services and empowered to advocate for them. Fourth, by investing in rigorous program evaluation of prevention implementation and programming, we can build evidence for earlier more ubiquitous services that can benefit all of society and prevent CPA before it occurs.

Cross-References ▶ Abusive Head Trauma: Understanding Head Injury Maltreatment ▶ Child Welfare System: Structure, Functions, and Best Practices ▶ Corporal Punishment: Finding Effective Interventions ▶ Corporal Punishment: From Ancient History to Global Progress

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▶ Parents Who Physically Abuse: Current Status and Future Directions ▶ The Impact of Neighborhood-Based Interventions on Reducing Child Maltreatment

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Contents A Description of Child Fatality Review Teams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The History of Child Fatality Review Teams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Deaths of Young Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sudden Infant Death Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Infant Sleeping Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Shaken Baby Syndrome/Abusive Head Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Deaths Involving Intimate Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Information on CFRT Recommendations Regarding Young Children . . . . . . . . . . . . . . . . . . . . . Deaths of Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adolescent Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adolescent Homicide: Intimate Partner Fatalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The National Child Death Review Case Reporting System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusions: The Future Promise of Child Fatality Review . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Since the 1970s, multidisciplinary Child Fatality Review Teams (CFRTs) in the United States have reviewed childhood deaths, analyzed the data regarding the causes of childhood deaths, and made recommendations for the prevention of

This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. R. N. Parrish (*) Salt Lake County District Attorney’s Office, Salt Lake City, UT, USA e-mail: [email protected] T. P. Cross University of Illinois at Urbana-Champaign, Champaign, IL, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_291

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future child and adolescent deaths. This chapter explores how those teams were formed, how they have evolved over several decades, and how they are responding to new challenges. It reviews examples of recommendations made by CFRTs to prevent both child and adolescent deaths, and discusses the development of a national data system to enhance the prevention of child and adolescent deaths. Keywords

Child fatality review · Child death review · Child mortality review · Youth fatality review · CFRT The process of interdisciplinary review of child fatalities was first proposed in the 1970s in the United States with the intention of improving the identification, investigation, and prosecution of child abuse or neglect-related homicides. Child fatality review teams (CFRTs) work not only to review the causes of child deaths but also to improve the recognition and investigation of those deaths related to abuse. As of 2012, all 50 states of the United States have some form of child fatality review process. This chapter describes CFRTs and briefly reviews the history of their development. It then examines a number of trends in fatality review regarding both children (aged 0–10 at the time of death) and youth (aged 11–18 at the time of death). It also reviews a number of recommendations CFRTs have made and initiatives they have undertaken to prevent child deaths in the community.

A Description of Child Fatality Review Teams The purpose of CFRTs, which are also known as child death review teams or child mortality review teams, was well stated by Dr. Randell Alexander (2011). “Child death review teams provide an interdisciplinary means to better explore the causes of death in childhood; more accurately ensure that individual deaths are investigated and properly labeled; and enable the community to develop plans to better prevent such deaths (p. xix).” Dr. Alexander (2007) explains that the original impetus for the formation of CFRTs was “concerns about the occurrence of undetected homicide caused by child abuse” (p. 3). For some CFRTs, these remain their sole or primary focus. However, many CFRTs have evolved to take a public health approach and review the deaths of all categories of minors, including older children, and child deaths from all causes. This enables them to identify trends and make recommendations for preventing future deaths. The objectives of most CFRTs are to identify ways to prevent future deaths of the young, make recommendations to policy and difference-makers, educate the public about public health issues relevant to child deaths, and provide more support to agencies working with those who care for children. The central mechanism of CFRTs is to conduct meetings to review child death cases. Some teams meet regularly (often monthly), while other teams meet only when a child death occurs that needs review (Covington et al. 2005). If there are too many

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cases for a team to review, certain types of cases may have priority, for example, cases involving homicide, unintentional injury, suicide, or sudden infant death syndrome (SIDS), or cases involving a medical examiner and coroner (Covington et al. 2005). Some states have only a state-level team but most have a combination of state and local teams (Palusci and Covington 2014). Membership of most teams includes representatives of medical examiners’ or coroners’ offices, law enforcement agencies, children’s services agencies, prosecutor offices, mental health agencies, pediatric and other medical units, child abuse and suicide prevention programs, education departments, and first responder organizations. Some teams conduct an immediate review following an identified childhood death, to improve the quality of an early investigation and create opportunities to share information (Durfee 2007). Other teams conduct retrospective reviews of child deaths several months after the death, when team members have learned more. Some teams do both. Both approaches have improved the accurate identification of the causes of childhood death, promoted appropriate interventions to prevent future childhood deaths of similar type, and created a rich source of data relating to trends and changes in what is killing young people in the United States. A significant aspect of the CFRT function has been to connect investigators, especially those from smaller jurisdictions that do not handle many child death investigations, with experts in many different fields who can assist them with understanding the significance of the medical findings. Case reviews also provide a good chance for criminal and child protection investigators to inform medical experts and the forensic pathologist of significant investigative facts that help in forming the decision about cause and manner of childhood deaths. CFRTs use data obtained through the child death review process to make recommendations for preventing child deaths from abuse or neglect. Most statewide teams provide reports with recommendations either annually or biannually; often the reports are legislatively mandated (Covington 2011). The reports go to various governmental agencies, the legislative body, and often the governor’s office. They set out recommendations for policy changes, legislative action, and agency improvement. The U.S. Children’s Bureau (U.S. Department of Health and Human Services 2012) analyzed 67 CFRT reports to profile the types of recommendations made and the implementation or outcome of the recommendations. The report describes six types of recommendations: (1) improved collaboration; (2) increased funding; (3) strengthened organizational capacity; (4) improved policies/legislation; (5) increased public awareness/education; or (6) improved services delivery. Wirtz et al. (2011) assessed 1093 CFRT recommendations from 21 randomly selected reports. Team reports scored higher in the assessment of the problem needing to be addressed than in the quality of their written recommendations and in the actions taken on those recommendations. Wirtz et al. described a four-step “action cycle” for CFRTs: 1) defining the problem, 2) identifying risk and protective factors, 3) developing and testing interventions, and 4) assuring widespread adoption. The National Center for Child Death Review (NCCDR)’s program manual (Covington et al. 2005) is a thorough “how-to” guide for CFRTs. The manual covers everything from the purpose and reasons for conducting child death reviews, to confidentiality and barriers to sharing information, to best methods for reporting and

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influencing legislation and public policy. In addition to its primary text, the program manual features almost another 100 pages of “tools” for CFRTs, including forms, model reports, and checklists for ensuring effective reviews of various forms of child deaths.

The History of Child Fatality Review Teams Los Angeles County formed the first child fatality review team in 1978, and other local teams had developed in California, Missouri, South Carolina, and Oregon by the mid-1980s (Durfee et al. 2002). In reaction to increasing data and public awareness regarding the role of child abuse and neglect in child fatalities, grassroots efforts during the 1980s spread the establishment of a child fatality review process to many states, and statewide teams began to develop in the late 1980s. As CFRTs demonstrated their effectiveness, an increasing number of states began to develop them. Many were created and funded by state legislatures, some by local governments, and others continued to function under the umbrella of a state or local agency related to health or welfare of children. A landmark child fatality study in the 1990s that helped propel the CFRT movement focused on all injury deaths of children under age 5 over a 4-year period in Missouri (American Bar Association 1991). It proved that child abuse deaths are underreported and under-recognized. In 1991, the American Bar Association (1991) received grant funding to publish a document that called for the creation of CFRTs throughout the country and recommended that state legislatures fund them. In 1992, Dr. Michael Durfee et al. (1992) published a seminal paper in the Journal of the American Medical Association describing the need to expand child death review nationwide. In the Federal Child Abuse Prevention and Treatment Act (CAPTA) of 1993, Congress added a requirement that states include information on child death review in their program plans requesting grant funding. Within a short time, several national and nonprofit agencies published recommendations for establishing CFRTs. In 1995, the United States Advisory Board on Child Abuse and Neglect published “A Nation’s Shame,” which exposed the need to improve the identification and response to child fatalities and noted that 45 states now had some form of child fatality review program. Of the 26 recommendations in the report, several related to the need for all states to establish a statewide child fatality review process, with such teams also established at military bases and in Indian nations. By the end of the 1990s and into the new century, child fatality review teams began to focus not just on identifying and improving the response to child abuse related fatalities, but also on reviewing all fatalities in childhood. They expanded to adopt a public health focus and make recommendations to prevent deaths among everyone of age 18 and younger. The Maternal and Child Health Bureau was very active in the first decade of the new century in recommending and funding the expansion of CFRTs. It convened training conferences bringing together those involved in the child fatality review process from all over the country. In 2002, the MCHB awarded a 3-year grant to

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Michigan’s Public Health Institute to establish a National Center for Child Death Review. In 2003, the NCCDR developed a 191-page National CDR Program Manual (Covington et al. 2005), in which representatives of 25 states collaborated. The NCCDR was funded again in 2005 and 2009 and was instrumental in developing the CDR Case Reporting System and disseminating it to the CFRTs. In 2011, the NCCDR changed its name to the National Center for the Review and Prevention of Child Deaths (NCRPCD) and continued to provide assistance and coordination as fetal and infant mortality review teams and domestic violence review teams were formed. In 2010, the American Academy of Pediatrics published a policy statement in which Dr. Cindy Christian and other authors stated that “the purpose of child fatality review is to identify effective prevention and intervention processes to decrease preventable child deaths through systematic evaluation of individual child deaths and the personal, familial and community conditions, policies, and behaviors that contribute to preventable deaths. . .Although originally developed to improve identification and prosecution of cases involving fatal abuse, the role of CFRTs has expanded toward a public health model of prevention of child fatality through systematic review of child deaths, from birth through adolescence” (Christian et al. 2010, p 593). The article emphasizes the critical role that pediatricians play in both the death review process and the identification and implementation of effective methods of prevention. It points out many advantages of child fatality review for both clinicians, who regularly work with surviving children and attempt to treat those who are fatally injured, and forensic pathologists, who focus on deceased children. The federal Protect Our Kids Act of 2012 resulted in the appointment of a Commission to Eliminate Child Abuse and Neglect Fatalities (CECANF). The Commission traveled to 11 different U.S. jurisdictions and met with local experts on child maltreatment fatalities; many of them were members of CFRTs (Commission to End Child Abuse and Neglect Fatalities 2016). The Commissioners summarized the problem in their report: Thousands of children die each year in the United States at the hands of those who were supposed to protect them. Overwhelmingly young and unthinkably vulnerable, they die from abuse—beatings and brain injuries—inflicted by their parents or caretakers. They die from neglect, including starvation, inadequate medical care, unsafe co-sleeping, or drowning in the bathtub. (p.18)

The Commissioners recommended reforming the child protection system, which had struggled to reduce child fatalities for decades. They focused on the need for government leadership, guidance, and funding at all levels: In short, now is the time to move away from old patterns and adopt a new course of action to prevent child maltreatment deaths. Now is the time for a 21st century strategy to protect children and support families. Our work responds to a national crisis. We are providing recommendations for the policy changes, tools, and strategies that we believe are needed to turn this tragic emergency around. (p. 21)

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In their summary, the Commissioners conclude with: We are convinced that this country can find the political wisdom, courage, and resources to save the lives of children. We must build a more comprehensive child welfare system that goes beyond CPS agencies and uses a public health approach to develop community capacity to help families and prevent abuse and neglect before problems turn into tragedy. We believe that our recommendations do this—that they address the multiple systemic and individual causes of child maltreatment deaths—whether or not the family was known to CPS agencies. (p. 121)

It remains to be seen whether the specific recommendations of the CECANF and/or the statements of Congressional intent in the Protect Our Kids Act of 2012 will actually result in change. But at least these efforts have led to progress in the ways CFRTs obtain and share information, and in developing more uniform ways of identifying and tracking child maltreatment fatalities. They have also informed law enforcement and child protection agencies of ways to work more efficiently toward a common goal of reducing and preventing future child deaths. If the Commission is correct in forecasting that this country does have the wisdom, courage, and commitment to make a difference, there should be an enhanced role for the CFRTs across the nation. As we close the second decade of the new century, both state and local CFRTs continue to play a vital role in both identification and prevention of deaths for young children and adolescents. Although some teams continue to review only a sample of childhood deaths, or only those related to abuse or neglect, most teams have expanded to include a review of all deaths of children under the age of 18. Some teams have begun to review “near deaths” of children as well. In many jurisdictions, local teams also provide data to the statewide team to inform prevention recommendations. Many early barriers to obtaining and sharing information among different agencies have been removed or modified to allow a more efficient and accurate review of all the social, family, and forensic circumstances surrounding the cause of childhood deaths. Although those CFRTs that have expanded to review all deaths of minors have gathered data and made prevention recommendations relating to many different causes of child and adolescent deaths, this chapter will concentrate on those causes that specifically relate to interpersonal violence. The focus in relation to younger children will be child homicide and neglect-related deaths. The focus in relation to adolescents will be on homicide and suicide. Readers should remember, however, that teams often review all causes of death including accidental, motor vehicle, natural, and other causes, in order to identify public health issues and make recommendations about them.

Deaths of Young Children Data from CFRTs and many other sources have consistently shown that the majority of child abuse and neglect fatalities occur in children under the age of three, and almost half of all maltreatment-related fatalities occur in children under 12 months of age (Child Welfare Information Gateway 2019). CFRTs identify the most frequent

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causes of death for young children as accidents, physical abuse or neglect, and natural causes. In 2017, children’s parents were responsible for 80% of abuse and neglect fatalities. Almost three quarters of child abuse and neglect fatalities were at least partially related to neglect, with abuse a cause in 41%. CFRTs’ recommendations for prevention of child fatalities have focused on preventable accidental deaths, abuse, and neglect fatalities for young children. Those CFRTs that have expanded to review all child deaths from a public health approach have also made significant efforts to identify risk and protective factors relating to the causes of all child deaths. They have encouraged a community approach to prevention that ensures that parents and caregivers of children have the support and services they need to help prevent abuse or neglect that result in a child fatality. From their inception, CFRTs have found ways to ensure that child homicides caused by child abuse or child neglect are adequately identified in the forensic and medical death investigation process as well as in law enforcement investigations and criminal prosecution or civil child protection actions. That effort has resulted in an increase in accurate identifications of young childhood deaths that are the result of abuse or neglect, and in system improvements in training, collaboration, and sharing of information between agencies. The effort has also generated recommendations to prevent such fatalities through public education, positive parenting training, hospital-based prevention programs, and other methods. CFRTs also support enhancing mental health and substance abuse treatment programs for parents who need assistance with their own problems so they can act appropriately and safely in raising their children. The function of ensuring adequate forensic and law enforcement investigation of child deaths continues to be a vital part of the CFRTs, especially since the multidisciplinary nature of the teams allows involved professionals to staff each case and learn from each other.

Sudden Infant Death Syndrome CFRTs help address the challenges of investigating sudden infant death syndrome (SIDS) cases. The CDC defines SIDS as “the sudden death of an infant less than one year of age that cannot be explained after a thorough investigation is conducted, including a complete autopsy, examination of the death scene and review of the clinical history.” A diagnosis of sudden unexplained infant death or sudden infant death syndrome is not appropriate without a full and adequate death investigation that includes a crime scene evaluation and considers the possibility of an unrecognized or carefully concealed homicide (Levene and Bacon 2004). CFRTs have played a significant role in evaluating both medical and law enforcement investigations when the cause of the infant’s death remains unexplained despite multidisciplinary review. In addition, CFRTs have been instrumental in convincing law enforcement agencies to use the sudden unexplained infant death forms developed in the 2000s (see Centers for Disease Control 2018), to help insure that medical examiners and coroners get the answers they need to make adequate determinations of cause of death.

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Infant Sleeping Practices One of CFRT’s contributions to protecting infants concerns safe sleeping practices. Over the past two decades, CFRTs have documented how infants in unsafe sleep positions are at greater risk of death and have often made recommendations about safe sleep positions for babies. CFRTs have facilitated what can generally be referred to as “Back to Sleep” campaigns. These campaigns have featured mass media messages, hospital-based training for parents of newborns, and inhome visitation programs. They have coordinated efforts among pediatricians to educate parents and remind them during well-child visits about the keys to safe sleep environments. These public information efforts have resulted in a measurable decrease in unexplained infant deaths (Trachtenberg et al. 2012; Kassa et al. 2016).

Shaken Baby Syndrome/Abusive Head Trauma Data from CFRTs have consistently shown that abusive head trauma, much of it relating to angry caregivers shaking babies, accounts for a large percentage of deaths for children under age one. Many CFRTs have made recommendations about the dangers of shaking a baby or young child. CFRTs’ work has informed the development of primary prevention campaigns related to child head trauma. The most successful abusive head trauma primary prevention efforts have often involved hospital-based education and training of new parents before they leave the hospital with their newborn. Dias et al. (2005) detailed the elements of a hospital-based program of education provided to all parents of newborns in Western New York State. Parents were asked to sign a commitment statement indicating they had received training and guidance about dealing with stress and dangers of shaking a baby and that they would pass on that information to anyone who was left to care for the baby. Sixteen regional hospitals participated in the effort over a 66-month period. A large proportion of parents participating in the program reported that they had learned the dangers of shaking a baby and committed to use the methods they learned about coping with their new babies crying. Participating hospitals reported a 47% decrease in the incidence of abusive head trauma cases in the 66-month period following implementation of the program. CFRTs in many other states recognized the efficacy of this primary prevention program, resulting in hospital-based prevention efforts in many other jurisdictions. Influenced by Dr. Ronald Barr’s research on the causes of infant crying (Barr 2014), the National Center on Shaken Baby Syndrome has promoted the use of the Period of Purple Crying program. Purple Crying communicates to new parents that sometimes they cannot do anything to stop an infant from crying. It offers education about what to do when a parent is stressed by a young child’s behavior, including the crying that is natural during early infancy. Several CFRTs have recommended the program, which several children’s hospitals and

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other community agencies have adopted in the USA and Canada. Dr. Barr’s research has established that young infants have a peak incidence of crying between 2 and 4 months of age. Meeting all their needs and using common soothing behavior do not stop the crying of some babies. This is contrary to the beliefs of most new parents, who feel guilty if they cannot cease the babies’ crying. Dr. Barr found that this period of normal and sometimes inconsolable crying corresponds with the peak incidence of inflicted head trauma in young infants. He worked with the National Center on Shaken Baby Syndrome to develop the Purple Crying curriculum, which includes guidelines for new parents to follow when normal soothing methods do not work. Parents receive a DVD and printed educational materials soon after the child’s birth. Parents are advised to place the baby in a safe place if normal soothing methods do not stop the crying, allow themselves to calm down, and then return to check on the baby. Barr et al. (2009) found that Purple Crying increased new parents’ awareness of the dangers of shaking and helped them formulate plans to handle the stress of infant crying. Research on a statewide program in North Carolina found that the program decreased parental calls about infant crying to a nurse crisis line (Zolotor et al. 2015). CFRTs have often commented in their reports about this program and others intended to decrease the incidence of abuse related to infant crying or similar triggers.

Child Deaths Involving Intimate Partners Another good example of taking data learned through child fatality reviews and crafting a prevention effort is Ohio’s Choose Your Partner Carefully campaign. First launched in 2008, this program is now also used as a model in Nevada and is being considered in other jurisdictions. Following a spate of child deaths at the hands of their mother’s paramours, the Ohio Child Fatality Review Board recommended “teaching parents to identify responsible adults as caregivers for children.” The Ohio experience was, of course, not isolated, as virtually every jurisdiction in the country has identified at least some child abuse or neglect related fatalities resulting from action or inaction by a paramour. Child protective services workers, criminal investigators, and prosecutors have always recognized that a significant number of child fatalities were at the hands of those who should never have been left in the sole care of the victims. A caseworker in Lorain County, Ohio, first crafted Choose Your Partner Carefully, and other Ohio counties adapted and expanded it within a few years. It was described in the CECANF report cited above and has also been promoted by the Prevent Child Abuse America organization. The program’s message is “choose your partner carefully, your child’s life depends upon it.” Choose Your Partner Carefully’s public information campaign uses social media, brochures, and public service announcements. It explains the risk parents take when they trust their paramour to be a competent and safe caregiver for the children just because the parent loves him or her. Toolkits for single parents often

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feature the following list of “warning signs,” even one of which should result in the parent not leaving their children alone with their partner (Lucas County, Ohio n.d.): • • • • • •

Does he/she get angry when you spend time with your child? Does he/she get angry or impatient when your child cries or has a tantrum? Does he/she call your child bad names or put them down? Does he/she think it’s funny to scare your child? Does he/she make all the decisions for you and your child? Does he/she put you down or tell you that you’re a bad parent or that you shouldn’t have your kids? • Does he/she pretend when he/she hurts your child that you are to blame or that it’s no big deal? • Does he/she tell you that our child is a nuisance or annoying? • Does he/she scare your child by using guns, knives, or other weapons? Similar lists have been published in other counties in Ohio and in Nevada. These lists represent the collective experiences of CFRTs all over the country when dealing with abuse and neglect deaths caused by live-in paramours of the child victim’s parents. While they are clearly based on common sense, it has been widely acknowledged that single parents sometimes fail to follow rules like these, especially in the early stages of a new relationship or when exigencies of finding a caregiver for their children influence parents’ judgment.

Information on CFRT Recommendations Regarding Young Children A 2012 review of CFRT recommendations found that almost all teams made recommendations regarding education of parents and caregivers about safe sleep practices, and that many had success supporting media campaigns and hospitalbased education programs (U.S. Department of Health and Human Services 2012). Team recommendations relating to reducing deaths from child abuse and neglect included increasing training for those tasked with investigation, improving collaboration, and sharing of information between agencies. Additional recommendations focused on public education about identifying the signs of abuse, implementing primary prevention programs to provide parents and caregivers the support they need before a crisis occurs, increasing home visitation, taking advantage of and expanding existing hospital-based child abuse and neglect prevention programs, and changing judicial practices (Child Welfare Information Gateway 2019). CFRTs also recommended education programs on coping with the stress of parenting and on recognizing and teaching others the risk of inflicting childhood head injuries. Notable recommendations by state and local CFRTs regarding prevention of mortality among young children since the 2012 review include the following: • Montana Child Fatality Review Report (2018) – recommended that the child welfare agency eliminate referring to those who cause deaths of young children as

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“unknown,” when in fact the CFRT review process revealed the identity of the perpetrator. Kentucky Public Health Child Fatality Review Program (November 2017) – helped create free text messaging program (Text4baby) providing health messages to expecting mothers and mothers of newborn babies. Washington, DC, Office of the Chief Medical Examiner Fatality Review Unit (2018) – recommended comprehensive hospital-based education for all parents of newborns on postpartum education, breastfeeding, family planning, safe sleep practices, tobacco exposure, vaccinations, car safety, and basic newborn care. New York City 2010–2015 Child Fatality Review Advisory Team Report – recommended public education to recognize parental mental health problems and promote referring parents to treatment. Nevada 2012 Annual Report of Child Deaths in Clark County – promoted networks of services, including parental stress management training, to help families most at risk in order to prevent incidents of fatal violence. Virginia Eastern Regional Child Fatality Review Team FY 2017 report – recommended that CFRT members conduct “grand rounds” for local hospitals on such prevention topics as parental distraction and addiction to technology, safe feeding, swaddling, and choosing a day care provider.

Deaths of Adolescents While adolescents sometimes die as a result of abuse or neglect, the great majority of adolescent deaths are due to accidents, homicide, suicide, or other causes. As child fatality review teams developed a new focus on public health and expanded their function to review all deaths of people under age 18 years, many teams began to recognize emerging patterns regarding the deaths of adolescents. Child fatality review teams have been at the forefront of recognizing trends in the cause of adolescent death in the United States. The causes of adolescent deaths reviewed by CFRTs include inexperienced and distracted driving, firearm accidents, dangerous and risky behaviors, and homicide and suicide. Some states have created suicide review teams in response to exponential increases in pre-teen and teen suicide rates over the last two decades. The focus here will be on those adolescent fatalities that involve interpersonal violence, including suicides, many of which are motivated by actions of others. Homicides of children age 10–18 are increasing, and the great majority are the result of firearms. Many fatal attacks reviewed by CFRTs occur in intimate relationships involving adolescents much younger than the public realizes. CFRTs have made well-documented and thoroughly researched recommendations regarding guns and firearms. The National Center for Health Statistics reported that homicide rates among adolescents increased 27% in 2016 and have been increasing since. The suicide rate for persons aged 10–19 years increased by 56% between 2007 and 2016. According to the report, these increases contributed to a record-setting number of adolescent injury deaths. The authors of the report note also that suicide is believed to be

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underreported in general, and the actual numbers may be much higher. A report by Child Trends shows that teens dying from firearm related causes increased nearly 30% between 2013 and 2017, and that the 11.8 per 100,000 rate of teen suicide documented in 2017 represents an all-time record high, with suffocation continuing to represent the most often lethal means for committing suicide (Child Trends 2019). These increases in adolescent homicides and suicides have established a public health crisis. It requires input from CFRTs as well as the health and mental health care systems.

Adolescent Suicide Virtually all CFRTs, whether local teams or statewide teams, have noted the increase in adolescents taking their own lives throughout the 2007–2019 period in the United States. This has led CFRTs to focus on the need to identify risk factors for suicide; to educate parents, extended family members, friends, educators, and others to recognize those who may need help or intervention; to increase the effectiveness and availability of mental health treatment for adolescents; and to make recommendations regarding removing lethal means for committing suicide. While case reviews often leave team members perplexed as to why a particular teen took his/her life, it can universally be said that suicide in this age group is as complicated as adolescence itself. No particular pattern of behaviors or precipitating factors is common enough in suicide cases to be more than one in a general list of risk factors. Warning signs may include suicidal threats or thoughts, previous suicide attempts, preoccupation or obsession with death, depression, and seeking or obtaining lethal means to commit suicide (See, e.g., United Health Foundation 2017). CFRTs are often baffled by particular teen suicides in which none of the often identified precedents were apparent, and the decedent was a high academic achiever and appeared to have no unusual stressors in his/her life. Because of the wide variety of triggers, motivations, and causes of teen suicide, many CFRTs have partnered with the health department or medical examiner’s offices on psychological autopsies, in which in-depth investigations are done to discern better ways to avoid future suicides of adolescents. According to Clark and Horton-Deutsch (1992), “The phrase ‘psychological autopsy’ refers to a procedure for reconstructing an individual’s psychological life after the fact, particularly the person’s lifestyle and those thoughts, feelings, and behaviors manifested during the weeks preceding death.” Many state health departments and injury prevention agencies have employed psychological autopsies to examine suicides and help develop ways to prevent them in the future. For example, the Utah Department of Health’s Violence and Injury Prevention Program (VIPP), which works with Utah’s CFRT, conducted the Utah Youth Suicide Study. The intense interest in adolescent suicide prevention in Utah began as suicide surpassed unintentional injury deaths as the leading cause of death for youth ages 10–19 in Utah in 2013 (Utah Department of Health 2015). The Utah Youth Suicide Study determined that 150 youths aged 10–17 died by suicide from

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2011 to 2015, that 78% were male, over a third had mental health diagnoses and well over half experienced a recent crisis. Fifteen percent were identified as sexual minorities, almost half left a note, and almost a quarter had a history of cutting or self-harm behavior. Interestingly, 12.6% had experienced a “technology related restriction” prior to death. The Utah Child Fatality Review Committee joined with the VIPP to make recommendations in response to the Utah Youth Suicide Study. One recommendation, for example, was to educate the media about how to report on youth suicides in a way that minimized the risk of copycat or cluster suicides. One of CFRTs’ most frequent recommendations regarding adolescent suicide has been to implement restrictions on access to firearms or other lethal means, especially when any risk factors for suicide are present (Rimsza et al. 2002). Rimsza et al. noted that Arizona’s CFRT considered the great majority of suicide deaths in the state over a 5-year period to be preventable. The team recommended strategies to reduce children’s access to guns, better availability of mental health services, and education of parents and teachers regarding the signs and symptoms of adolescent depression and the risks of keeping firearms in the home unsecured when a depressed teen is present (Id. p. 4,5). CFRT recommendations have been one important source of information that contributed to the development of a national suicide hotline (1–800273-TALK) as well as state-based crisis lines for adolescents to get nonjudgmental help when they feel hopeless and on the verge of self-harm. The Georgia Child Fatality Review Panel Annual Report for 2016 (Georgia Child Fatality Review Panel 2016) is a good example of how state CFRTs are addressing the problem of adolescent suicide. The report lists the factors that precipitated the 51 adolescent suicides they reviewed that year. The list is quite common for all CFRTs reviewing suicides. The report notes that asphyxia was the leading method for suicide, followed closely by firearms, with just a few poisoning deaths. The report recommends targeted education for all youth in all levels of public schools about risk factors and warning signs of suicide, training school staff to recognize the warning signs and respond effectively, and restricting access to lethal means of suicide such as firearms and lethal medications. Other CFRTs have also recommended interventions after a suicide that focus on family and close friends of the decedent to help prevent or limit “suicide clusters.” They have recommended developing assessment tools to assess the risk of suicide for students expelled from school or arrested and detained for juvenile delinquency. A review of multiple CFRT reports relating to suicide and suicide prevention among adolescents reveals several recommendations that were made almost universally. These include removing lethal means in households with troubled or depressed teens, taking warning signs seriously and aggressively seeking treatment for those who have expressed suicidal thoughts or plans, expanding mental health treatment for teens, and destigmatizing seeking help for depression or other mental health problems. While there is no doubt that states have now refocused efforts toward recognition and prevention of suicides, it remains to be seen whether those efforts will result in an actual reduction in numbers as the third decade of this century begins.

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Adolescent Homicide: Intimate Partner Fatalities CFRTs have also been troubled about the steady rise in recent years in the number of adolescent homicides. Some of this rise relates to gang activity and some to recent increases in intimate partner violence. A large majority (87%) of homicides for both males and females between 10 and 19 years of age between 1999 and 2016 are the result of firearm use. Given the data that firearms are involved in most adolescent homicides, the American Academy of Pediatrics has issued a policy statement recommending that clinicians take an active role in advising families and patients about firearms, and in advocating for legislative and policy changes (Parikh et al. 2017). It is of great concern to CFRTs that Hispanic or Black youth die by homicide at a much higher rate than teens of other races. Finding solutions for reducing these homicides will never be easy and will require a concerted effort by everyone in communities with active and informed government leadership. CFRTs have made several recommendations for prevention. In its latest annual report, the Arizona’s Child Fatality Review Board (2018) reviewed an increased number of adolescent firearm-related suicides and homicides and found that all the homicides were preventable. The CFRT recommended that “owners should store all firearms in a safe condition; unloaded and in a secure locked location.” The Texas Child Fatality Review Team Committee, in their 2018 annual report, recognized that assault was the primary cause of homicides among adolescents and that 89% involved a firearm, most often owned by a family member. This SCFRT recommended a statewide Safe Storage Campaign for gun safety. The Clark County Nevada CFRT’s annual report of 2012 recommended that prevention efforts aimed at reducing firearm related youth homicides should focus on meeting the needs of adolescents through community-based outreach programs and gang prevention activities. An important subset of adolescent homicides involves intimate partner violence (Adhia et al. 2019). Adhia et al. (2019) conducted the first analysis of adolescent intimate partner homicide based on data from the National Violent Death Reporting System between 2003 and 2016. Among 2188 homicides for victims between age 11 and 18, 150 were intimate partner homicides (6.9%). In 90% of these intimate partner homicides, the victims were female, and in 77.9% of them the perpetrators were 18 years of age or older. Not surprisingly, firearms were the most common mechanism of fatal injury. The authors noted that adolescent girls in dating relationships face an elevated risk of homicide when there is a break-up or jealousy and when the perpetrator has access to firearms. The authors noted that in many states, adolescents cannot seek a protective order because they do not “cohabitate” with the offender or because they need parental consent and do not want to disclose the problem to their parents. Thus, they recommend, “all states should strongly consider the adoption of statutes that allow adolescents experiencing IPV to apply for civil protection orders without

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parental consent” (p. 576), regardless of whether the victim cohabitates with the perpetrator of physical or emotional violence. CFRT recommendations relating to prevention of teen dating homicide and violence include the following: • Begin early in school teaching children about healthy relationships and providing them a basis for understanding the difference in abusive relationships • Make clear to teens that dating violence, bullying, shaming, or forced sexual activity is not normal and not something to be tolerated in silence • Take advantage of the CDC’s Preventing Intimate Partner Violence Across the Lifespan: A Technical Package of Programs, Policies, and Practices • Ensure schools adequately train staff, teachers, counselors, and administration about the risks of interpersonal violence; how to recognize the early warning signs; how to address if reported; and how to talk to students about the issue • Safety planning with local law enforcement agencies, domestic violence support agencies, and school security personnel • Recognize that dating violence, bullying, and psychological maltreatment are major risk factors for both suicide and homicide, especially if the aggressive partner in the relationship has access to lethal means • Educate the media and the public about the reality of adolescent intimate partner violence, and the risk of homicide

The National Child Death Review Case Reporting System For many years, one important nationwide concern has been the inability to obtain complete and accurate information relating to child deaths. A number of local teams have developed information-sharing agreements over the years, but the development of the web-based National Child Death Review Case Reporting System (NCDRSCRS) by the National Center for Child Death Review represents a major step forward. Developed between 2002 and 2005, this web-based dataset aims to capture not just the outcome of child death case review but the context in which the death occurred. In 2011, the NCDRS-CRS contained over 1700 data elements. As of 2019, 45 states were participating in the NCDRS-CRS. The use of a uniform reporting system seemed to be improving both the data being identified by CFRTs and the accurate analysis of problems, which could yield recommendations for policy and legislative changes to protect children (Child Welfare Information Gateway 2019). Palusci and Covington (2014) reviewed cases reported to the NCDRS-CRS by 23 states between 2005 and 2009 and found that among 47,947 child deaths in which CFRTs had conducted a complete review, child maltreatment caused or contributed to 2,285 of them. The authors note that the largest cause of child fatality remains neglect among younger children, but that physical abuse and abusive head trauma

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also accounted for a substantial number of deaths. Most significantly, Palusci and Covington note that “The NCDRS-CRS allows users to describe their recommendations and strategies being planned and implemented. Of the 2,285 maltreatment deaths analyzed here, 1,020 cases had actions or strategies recommended or planned, and teams recorded that 109 were actually implemented as of July, 2012, p. 34.”

Key Points • Child fatality review teams (CFRTS) work not only to review the causes of child deaths but also to improve the recognition and investigation of those deaths related to abuse. • The central mechanism of CFRTs is to conduct meetings to review child death cases. • Membership of most teams includes representatives of medical examiners’ or coroners’ offices, law enforcement agencies, children’s services agencies, prosecutor offices, mental health agencies, pediatric and other medical units, child abuse and suicide prevention programs, education departments, and first responder organizations. • CFRTs have improved the accurate identification of the causes of childhood death, promoted appropriate interventions to prevent future childhood deaths of similar type, and created a rich source of data relating to trends and changes in what is killing young people in the United States. • A significant aspect of the CFRT function has been to connect investigators with experts who can assist them with understanding the significance of the medical findings. • CFRTs use data obtained through the child death review process to make recommendations for preventing child deaths from interpersonal violence. • Beginning in 1978, CFRTs have developed in all 50 states and in many local communities. • By the end of the 1990s, many child fatality review teams adopted a public health focus and began reviewing all fatalities in childhood. • Data from CFRTs and other sources show that the majority of child abuse and neglect fatalities occur in children under the age of three. • CFRTs identify the most frequent causes of death for young children as accidents, physical abuse or neglect, and natural causes. • CFRTs have increased the accurate identification of young childhood deaths that are the results of abuse and neglect. • CFRTs have generated recommendations to prevent fatalities of young children through public education, positive parenting training, hospital-based prevention programs and other methods. • CFRTs help address the challenges of investigating sudden infant death syndrome (SIDS) cases.

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• CFRTs have documented how infants in unsafe sleep positions are at greater risk of death and have often made recommendations about safe sleep positions for babies. • Data from CFRTs have consistently shown that abusive head trauma accounts for a large percentage of deaths for children under age one and have made recommendations about the dangers of shaking a baby or young child, the cause of much of this head trauma. • CFRTs have promoted Choose Your Partner Carefully campaigns designed to prevent child deaths at the hands of paramours. • The causes of adolescent deaths reviewed by CFRTs include inexperienced and distracted driving, firearm accidents, dangerous and risky behaviors, and homicide and suicide. • To prevent adolescent suicide, CFRT reports recommend removing lethal means in households with troubled or depressed teens, taking warning signs seriously and aggressively seeking treatment for those who have expressed suicidal thoughts or plans, expanding mental health treatment for teens, and destigmatizing seeking help for depression or other mental health problems. • CFRT recommendations relating to prevention of teen dating homicide and violence include the following: teaching children about healthy relationships, making it clear that interpersonal violence is not normal and should not be tolerated, training schools about interpersonal violence, utilizing safety planning with law enforcement and other agencies, recognizing that victims of dating violence and other interpersonal violence are at risk for committing suicide or homicide, and educating the media and public about adolescent intimate partner violence and homicide. • The National Child Death Review Case Reporting System has been developed to capture data on both the outcome of child death case review and the context in which the death occurred.

Summary and Conclusions: The Future Promise of Child Fatality Review Ultimately, the goal of Child Fatality Review Teams has been refined to identifying trends and patterns in the causes of childhood deaths, documenting all the data that illuminate those causes and then using that information to recommend prevention methods. Most CFRTs are now using new internet-based uniform data collection systems. This creates a real opportunity to use data to inform national initiatives to focus on the most common causes of child fatality. Most CFRTs have noted that their function is not to implement the recommended policy and public health practices but to make and defend recommendations based on verifiable data. So, for instance, the Pennsylvania Child Death Review Annual Report for 2017 noted “It is important to note that local CDR teams are not expected to provide all the prevention efforts in a community. Instead, teams should tap into resources currently available and share

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information about the factors surrounding deaths with other partners to aid in identifying and developing prevention strategies” (Pennsylvania Department of Health, 2017, pp. 5–6). As teams follow the guidance of Dr. Stephen Wirtz and improve the quality and feasibility of their action recommendations, the result should be a measurable change in public attitudes, in state and federal legislation, and in state and local investigative agency policies and procedures. Hopefully CFRTs can help society make preventing childhood deaths a high priority. The challenge for the future of child fatality review teams will not be limited to using the new web-based data collection system to improve their underlying data collection. CFRTs will then need to obtain the resources, support, and abilities to identify preventable causes of child deaths and to make concrete recommendations addressed to the agencies, individuals, or policy makers who can make a difference. They will also need to follow through to make sure recommendations are actually acted upon. The recent spread of awareness of the effects of adverse childhood events, resulting in trauma-focused training being required in almost every state, provides a good example of how positive changes can be accomplished with the appropriate approach based on accurate data and a specific plan for implementation directed to the right people. Most CFRT reports acknowledge that between 25% and 75% of all child and adolescent deaths from all causes are preventable. It is almost universally recognized that almost all adolescent homicides and suicides are preventable. CFRT reports yield a rich source of well-documented recommendations for prevention. It is now up to policy makers to recognize that the majority of deaths of children in the United States are preventable and to shift resources to improving the safety of our children, making the future better for all of us. Implementation of CFRTs’ data-based recommendations has sometimes been slow because of ever-changing political priorities of lawmakers and other policy makers. Hopefully, the policy makers and holders of the purse strings will be encouraged to change many of their historical priorities and make protecting children, including adolescents, an ascendant priority. For a variety of reasons, it has always been difficult to influence those individuals to accept the basic premise that our children represent our future in every possible way, and that all of us have a responsibility to make childhood safer whenever it is in our power to do so. “Even when deaths are correctly classified and tabulated and effective recommendations are made, the motivation for change by individuals or organized entities remains. Based on the number of recommendations made by CFRTs over the years, it is legitimate to question whether society cares enough about children to commit the necessary resources to reduce child fatalities” (Alexander 2007. p. 11). Although that was written in 2007, it adequately describes the current problems facing CFRTs in achieving implementation of their recommendations in 2020. Changing social norms is a very slow and difficult process. Yet, the previous majority acceptance of corporal punishment of young children in the United States is declining as more and more policy makers are exposed to the ACES Study and realize that adverse childhood experiences have a negative effect throughout the lifetime (Felitti et al. 1998; Merrick et al. 2018). Few would argue that recognizing and preventing the causes of child and adolescent deaths should not be at the top of our national

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priorities, yet many such prevention recommendations run afoul of entrenched feelings about such things as gun regulation and safety and skepticism about the abuse of young children by their caregivers.

Cross-References ▶ Abusive Burns ▶ Abusive Head Trauma: Understanding Head Injury Maltreatment ▶ Child Neglect ▶ Child Physical Abuse: A Pathway to Comprehensive Prevention ▶ Community Violence Overview: Guiding Principles, Critical Issues, and Prevention and Intervention Strategies ▶ Corporal Punishment: Finding Effective Interventions ▶ Corporal Punishment: From Ancient History to Global Progress ▶ Defining Gun Violence Using a Biopsychosocial Framework: A Public Health Approach ▶ Domestic Child Torture: Identifying Survivors and Seeking Justice ▶ Fractures ▶ Parents Who Physically Abuse: Current Status and Future Directions ▶ Siblicide: The Psychology of Sibling Homicide ▶ Teen Dating Violence Policy: An Analysis of Teen Dating Violence Prevention Policy and Programming ▶ The Nature of Neglect and Its Consequences

References Adhia, A., Kernic, M. A., Hemenway, D., Vavilala, M. S., & Rivara, F. P. (2019). Intimate partner homicides of adolescents. JAMA Pediatrics, 173, 571–577. Alexander, R. (2007). Chapter 1: Overview. In R. Alexander (Ed.), Child fatality review. Florissant, MO: GW Publishing. Alexander, R. (2011). Child fatality review. Quick reference. Florissant, MO: STM Publishing. American Bar Association Center on Children and the Law (1991). Child death review teams: A manual for design and implementation. Washington, DC: Author. Arizona Child Fatality Review Program. (2018). Twenty fifth annual report.. Retrieved from https:// www.azdhs.gov/documents/prevention/womens-childrens-health/reports-fact-sheets/child-fatal ity-review-annual-reports/cfr-annual-report-2018.pdf Barr, R. G. (2014). Crying as a trigger for abusive head trauma: A key to prevention. Pediatric Radiology, 44(Suppl. 4), S559–S564. Barr, R. G., et al. (2009). Do educational materials change knowledge and behavior about crying and shaken baby syndrome? A randomized control trial. CMAJ, 180(7), 727–733. Centers for Disease Control and Prevention. (2018). SUIDI reporting form. Website. Retrieved from https://www.cdc.gov/sids/SUIDRF.htm Child Trends. (2019, May 8). Teen homicide, suicide and firearm deaths. Retrieved from childtrends.org/indicators/teen-homicide-suicide-and-firearm-deaths

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Child Welfare Information Gateway. (2019). Child abuse and neglect fatalities 2017: Statistics and interventions. Washington, DC: U.S. Department of Health and Human Services, Children's Bureau. Retrieved from https://www.childwelfare.gov/pubs/factsheets/fatality/. Christian, C. W., & Sege, R. D., The Committee on Child Abuse and Neglect, & The Committed on Injury, Violence and Poison Prevention and The Council on Community Pediatrics. (2010). Child fatality review. Pediatrics, 126, 592–596. Clark, D. C., & Horton-Deutsch, S. L. (1992). Assessment in absentia: The value of the psychological autopsy method for studying antecedents of suicide and predicting future suicides. In Maris et al. (Eds.), Assessment and prediction of suicide (pp. 144–182). New York: Guilford Press. Covington, T. (2011). The U.S. National child death review case reporting system. Injury Prevention, 17(Suppl 1), i34–i37. Covington, T., Foster, V., & Rich, S. (2005). A program manual for child death review. Okemo, MI: National Center for Child Death Review. Retrieved from https://www.ncfrp.org/wp-content/ uploads/NCRPCD-Docs/ProgramManual.pdf. Dias, M., et al. (2005). Preventing abusive head trauma among infants and young children: A hospital-based, parent education program. Pediatrics, 115, 470–477. Durfee, D. (2007). Child death review teams, examples and overview, chapter 31. In R. Alexander (Ed.), Child fatality review: An interdisciplinary guide and photographic reference (pp. 503– 512). Florissant, MO: GW Publishing. Durfee, M. J., Gellert, G. A., & Tilton-Durfee, D. (1992). Origins and clinical relevance of child death review teams. JAMA: The Journal of the American Medical Association, 267, 3172–3175. Durfee, M., Durfee, D. T., & West, M. P. (2002). Child fatality review: An international movement. Child Abuse & Neglect, 26, 619–636. Felitti, A. V., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4), 245–258. Georgia Child Fatality Review Panel. (2016). Annual report. Calendar year 2016. Retrieved from https://www.ncfrp.org/wp-content/uploads/State-Docs/GA_OCFR_2016.pdf Kassa, M., et al. (2016). Risk factors for sleep-related infant deaths in in-home and out-of-home settings. Pediatrics, 138(5), 1–5. Levene, S., & Bacon, C. J. (2004). Sudden unexpected death and covert homicide in infancy. Archives of Disease in Childhood, 89, 443–447. Lucas County, Ohio. (n.d.). Warning signs. Webpage. Retrieved from https://www.co.lucas.oh.us/ 1919/Warning-Signs Merrick, M. T., et al. (2018). Prevalence of adverse childhood experiences from the 2011–2014 behavioral risk factor surveillance system in 23 states. JAMA Pediatrics, 172(11), 1038–1044. Palusci, V. J., & Covington, T. (2014). Child maltreatment deaths in the U.S. National child death review case reporting system. Child Abuse & Neglect, 38, 25–36. Parikh, K., Silver, A., Patel, S. J., Iqbal, S. F., & Goyal, M. (2017). Pediatric firearm-related injuries in the United States. Hospital Pediatrics, 7, 303–312. Pennsylvania Department of Health (2017). Pennsylvania Child Death Review Team annual report. 2017 annual report. Harrisburg, PA: Author. Retrieved from https://www.ncfrp.org/wp-content/ uploads/State-Docs/PA_CDR2017.pdf Rimsza, M. E., et al. (2002). Can child deaths be prevented? The Arizona child fatality review program experience. Pediatrics, 110(1), 1–7. Trachtenberg, F. L., et al. (2012). Risk factor changes for sudden infant death syndrome after initiation of back to sleep campaign. Pediatrics, 129(4), 630–638. U.S. Advisory Board on Child Abuse and Neglect. (1995). A Nation’s shame: Fatal child abuse and neglect in the United States. Washington DC: US Department of Health and Human Services. U.S. Department of Health and Human Services, Administration for Children and Families, Children’s Bureau. (2012). A review of state and local fatality review team reports:

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Recommendations and achievements. Retrieved from http://www.wrma.com/wp-content/ uploads/2014/10/Review-of-State-and-Local-Fatality-Review-Team-Reports.pdf United Health Foundation. (2017). Teen suicide. Webpage. Retrieved from https://www. americashealthrankings.org/explore/health-of-women-and-children/measure/teen_suicide/state/ ALL Utah Department of Health. (2015). Utah health status update: Risk and protective factors for youth suicide. Retrieved from health.utah.gov/vipp/pdf/Suicide/HealthStatusUpdateRiskandProtecti veFactorsforYouthSuicide.pdf Wirtz, S., et al. (2011). Assessing and improving child death review team recommendations. Injury Prevention, 17(Suppl 1), i64–i70. Zolotor, A., et al. (2015). Effectiveness of a statewide abusive head trauma prevention program in North Carolina. JAMA Pediatrics, 169(12), 1126–1131.

Section IV Neglect of Children and Adolescents Ernestine Briggs, Theodore P. Cross, Amy Russell, Michelle Clayton, Javonda Williams, Stacie Schrieffer LeBlanc, Heather J. Risser, Viola Vaughan-Eden, and Victor I. Vieth

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Contents Introduction: The Need for Neglect Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Etiology of Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Societal/Community Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Family Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Parent Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevention and Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Societal-/System-Level Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Family-Focused Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points Related to Child Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

The neglect of children is a widespread problem adversely affecting multiple domains of functioning throughout the lifespan. Repeated calls-to-action have noted the “neglect of neglect,” or lack of knowledge pertaining to neglect relative to abuse, particularly regarding prevention and intervention. Difficulties concerning neglect’s definition, identification, and public awareness and attention This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. J. M. Kobulsky (*) School of Social Work, College of Public Health, Temple University, Philadelphia, PA, USA e-mail: [email protected] H. Dubowitz School of Medicine, University of Maryland, Baltimore, MD, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_325

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to this problem impede progress. This chapter provides an update on research findings regarding neglect’s etiology, prevention, and intervention. Several studies on the predictors of child neglect have been conducted in recent years. There have been noteworthy advances regarding the prevention of and interventions for neglect. Although much work remains to be done, recent research has generated significant new knowledge concerning the neglect of children. Keywords

Child neglect · Risk factors · Protective factors · Etiology · Causes · Prevention · Intervention

Introduction: The Need for Neglect Research Neglect is a prevalent, consequential, but poorly understood societal problem. Defined as circumstances when a child’s basic needs are not adequately met resulting in actual or potential harm, neglect is the form of maltreatment most commonly reported to child protective services (CPS) in many countries (Gilbert et al. 2009; Proctor and Dubowitz 2014; US Department of Health and Human Services [USDHHS] 2019). A meta-analysis of prevalence studies estimated the global prevalence of physical neglect to be 16% and of emotional neglect to be 18% (Stoltenborgh et al. 2013). More recent prevalence rates ranged from 9% in Sweden to 94% in Burundi (Cater et al. 2014; Charak et al. 2017). In the USA, an estimated 25% of children will be reported to CPS for neglect in their lifetime (Kim et al. 2017). Our other chapter in this volume provides an update of research on neglect’s consequences, as well as its definitions, conceptualization, measurement and assessment, and prevalence. In general, recent research has documented associations between the neglect of children and adverse biological, cognitive, social, mental health, and physical health outcomes throughout the lifespan (Cecil et al. 2016; Maguire et al. 2015; McLaughlin et al. 2014; Naughton et al. 2013, 2017; Norman et al. 2012; Sullivan et al. 2013; Vanderminden et al. 2019; Vincent et al. 2017). The effects of neglect appear to be as pernicious as those of abuse (Vachon et al. 2015). Moreover, these effects pertain to multiple national and cultural contexts, indicating the significance of neglect as a global problem (Hecker et al.2018;Khaleque 2015; Kwak et al. 2018; Sun et al. 2019). The current chapter reviews recent literature on neglect’s etiology, prevention, and intervention. Repeated calls-to-action have been made for scientists to remedy the “neglect of neglect,” the relative inattention to child neglect in research (Widom 2013; Wolock and Horowitz 1984; US Department of Health and Human Services [US DHHS] 1997). In 2000, the Federal Child Neglect Research Consortium was organized to accelerate scientific progress in this area. The NIH, in collaboration with numerous other federal agencies, established the Child Abuse and Neglect Working Group and issued multiple Requests for Applications for child neglect research (Boyce and Maholmes 2013). In 2012, recognizing the particular lack of

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research on intervention and prevention strategies related to neglect, as well as abuse, the Pediatric Trauma and Critical Illness Branch was established within NICHD (Maholmes 2017). These efforts have resulted in several federal grants funding neglect research, such as a study of the dissemination and implementation of the Safe Environment for Every Kid (SEEK) model. The current review assesses the extent to which researchers have generated new knowledge on neglects’ etiology, prevention, and intervention in response to these calls. It broadly addresses the question: What is new about neglect? It focuses on advances made from 2012 to 2019 since Proctor and Dubowitz’s (2014) comprehensive review.

The Etiology of Neglect The etiology of neglect is often complex, involving multiple levels of dynamically related systems. Contributing factors are at the macro (societal, community), mezzo (familial contexts and interactions), and micro levels (individual parent and child) (Belsky 1993; Bronfenbrenner 1977, 1979). Prior reviews revealed many correlates of neglect, but identified limitations, such as unmeasured confounds, the paucity of prospective research, and the lack of attention to societal-level factors (Proctor and Dubowitz 2014). In addition, the need for more analysis of mediated and moderated processes leading to neglect was noted (Proctor and Dubowitz 2014). Recent studies have made notable advances to understanding risk and protective factors for neglect, including multiple levels of factors influencing neglect and mediated or moderated (e.g., context-specific) pathways (Table 1). This research together with clinical experience attests to there seldom being a single risk factor that explains why a child is neglected. Rather, there are typically multiple and often interacting factors underpinning neglect.

Societal/Community Context Recent research has begun to examine how contextual factors predict neglect. Population-level trends such as internal migration in China (i.e., individuals moving from rural to urban areas for work) lead to “left behind” and migrant children, both of which are associated with neglect (Chen et al. 2019). In a study of 42 countries, more children in households, child labor, gender inequality, less education and educational achievement, lower female literacy, and associated burdens such as poverty were associated with neglect (e.g., young children left in the care of other children; Klevens et al. 2018). A US study found more supervisory neglect in urban than rural areas, although the converse was found in an Indian sample (Beatriz et al. 2018; Esser et al. 2016). In general, community-level poverty appears linked to neglect (Bartlett et al. 2014). Neighborhood qualities such as reciprocated exchange (i.e., neighbors helping each other) have not been found to buffer the effects of poverty on child neglect, although informal social control (i.e., shared expectations and norms that

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Table 1 Summary of risk and protective factors for neglect identified by research 2012–2019 Societal context • Internal migration (multiple moves in living arrangement, changes in family structure) • Living farther from mental health services • More drug-related crime • Community-level poverty • Higher country-level average number of children in households, child labor, and gender inequality; lower level of education, literacy, standard of living, and life expectancy • Informal social control (shared neighborhood norms, reciprocity among neighbors) • Minimum wage

Family context • Family poverty • Two or more children in the home • Unmarried or single parents, not living with two biological parents • Difficulty arranging childcare/access to childcare subsidies • Violence in the home • Military deployment

Parent factors • Younger age, racial/ ethnic minority status, less education, unemployment • Unrealistic expectations of child, role reversal, attributions of hostile intent to child’s actions, belief that injuries are not preventable • Less “progressive” parenting attitudes, belief in corporal punishment • Low parental warmth, empathy • Poor executive functioning, cognitive impairment • Parenting stress and burnout • History of abuse or neglect • Intimate partner violence • Antisocial behavior, criminal offending • History of mental and physical health problems, depression • Substance use • Positive father involvement (protective factor)

Child factors • Sexual minority status • Perinatal and mental/ physical/behavioral problems including attention-deficit/ hyperactivity disorder, internalizing behaviors • Chronic and complex medical conditions

Note. Italics denotes mixed or relatively weak findings

shape behavior within a group) was associated with less neglect in higher-income families (Maguire-Jack and Font 2017). Factors such as the lack of safe childcare and recreational areas may contribute to neglect in poor areas (Elias et al. 2018). Living farther from mental health services and in areas with drug-related crime has also been associated with neglect (Freisthler et al. 2017; Maguire-Jack and Klein 2015). Contextual factors influencing neglect may vary by group. Researchers in one study probing the link between poverty and neglect found racial differences. Black children reported to CPS for neglect disproportionately experienced both family- and community-level poverty. Among neglected children, severe neglect was associated with relatively low community poverty in White children, while the opposite was

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found in Black families (Jonson-Reid et al. 2013). In sum, characteristics of a community, particularly those related to poverty, appear to clearly contribute to child neglect, but these relations appear to vary by racial group.

Family Context As noted above, community and family poverty are often linked. Family poverty, including low income, material hardship, and unemployment, is associated with child neglect, more strongly than with abuse (Albert and Lim 2018). Financial constraints make it more difficult for parents to meet children’s needs and can force them to prioritize some needs over others (e.g., having heat in winter vs. taking a child to the doctor; Elias et al. 2018). Parents in poverty may experience fatigue and high stress, often parenting alone with few safe and reliable social supports, while struggling with the challenges of community violence and associated child trauma (Elias et al. 2018). Neglect, however, is not synonymous with poverty and it has detrimental effects beyond poverty (Font and Maguire-Jack 2020). Lower socioeconomic status (SES) may not, moreover, be associated with all forms of neglect. In a US study, low-income families had higher rates of lifetime overall neglect, neglect due to inadequate food or medical care, and neglect due to inadequate supervision, compared with better-off families (Vanderminden et al. 2019). However, past-year neglect related to parental absence (child left alone without knowing parent’s whereabouts) was higher in middle- and high-income families than in those with low incomes (Vanderminden et al. 2019). In addition, financial strain has been associated with physical but not supervisory neglect (Turner et al. 2019). A meta-analysis of 36 studies found a variety of family-level risk factors for neglect, including unmarried parents, physical violence in the home, more than one child in the household, low SES, children not living with biological parents, and problematic parental behavior (i.e., low parental warmth, lack of empathy, role reversal with child) (Mulder et al. 2018). Other research has identified conditions such as difficulty arranging emergency childcare, perceived hardship, family structure other than two-parent families, and unemployment as risk factors for neglect, as well as having a cumulative effect (Vanderminden et al. 2019; Yang and Maguire-Jack 2018). Of note, low-income families’ receipt of childcare subsidies has been associated with less supervisory neglect (MaguireJack et al. 2019). There are population-specific risk factors, such as deployment in military families (Cozza et al. 2018b). Among military families with substantiated neglect, having more children in the home was associated with physical and supervisory neglect, but less emotional neglect (Cozza et al. 2018a). In addition, family disagreements were related to emotional neglect, mental health problems to physical neglect, and childcare problems to supervisory neglect. Thus, research supports the role of an array of family difficulties in contributing to neglect. While family poverty has long been associated with neglect, recent studies

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have refined our understanding of poverty as it relates to specific neglect subtypes. It also suggests important protective factors, including access to childcare subsidies and marriage/two-parent households.

Parent Factors Demographic characteristics. Young parental age and adolescent parenting, low level of education, unemployment, and racial/ethnic minority status have been associated with neglect (Bartlett et al. 2014; Lansford et al. 2015; Lee 2013; Mulder et al. 2018). Of note, however, a meta-analysis did not find parental unemployment per se and neglect to be associated (Mulder et al. 2018). The nature of the unemployment, however, such as its chronicity and recency may be important, as well as the family’s resources. Unemployment may increase parents’ time with children while presenting economic and social stress (Bullinger et al. 2019). Neglect subtype may also matter; a US study found that parental job loss and less education were associated with both physical and supervisory neglect, especially the latter (Turner et al. 2019). Parental cognitions. Studies using social information processing frameworks have found that social cognitive and neurocognitive difficulties are associated with neglectful parenting (Azar et al. 2017a,b). Unrealistic expectations of children, attributions of hostile intent to children’s actions, and poor executive functioning were similarly associated with neglect risk (Azar et al. 2017a,b). In a nine-country study, less “progressive” parenting attitudes toward corporal punishment as normative and necessary were risk factors for neglect (Lansford et al. 2015). Cognitive limitations and parental inability to follow medical advice due to low health literacy and communication difficulties with healthcare professionals have been linked to neglect (Logan-Greene and Semanchin Jones 2018; Parmeter et al. 2018). Parental stress, trauma, and isolation. In a non-clinical sample, maternal stress related to infant temperament was a risk factor for neglect in young children (6 months to 4 years), as was stress reconciling work and family demands in fathers of children 6 months to 9 years old (Clément et al. 2016). Parental burnout, a syndrome related to overwhelming stress and involving exhaustion related to parenting, emotional distancing from children, and a sense of ineffectiveness in the parental role, influenced neglectful behaviors toward children in a mostly Belgian sample (Mikolajczak et al. 2018). Intimate partner violence has also been associated with neglect (Bartlett et al. 2014; Logan-Greene and Semanchin Jones 2018; Yang and Maguire-Jack 2018). Exposure to such violence can also be considered a type of neglect per se, given children’s need to live in a safe and secure home. Parental history of abuse and neglect is a risk factor for neglect; in one study, young mothers who experienced neglect were 60 times more likely to neglect their own children (Bartlett et al. 2014, 2017; Mulder et al. 2018; Yang and Maguire-Jack 2018). Parental health. Mulder et al.’s (2018) meta-analysis found links between parental mental and physical health problems, antisocial behavior, criminal

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offending, and neglect. Consistent with past research, maternal depression has been associated with neglect (Clément et al. 2016). Parental mental health appears to mediate relations between parental violence exposure and neglectful behaviors. In one study, the influence of parental history or abuse and neglect on child neglect was mediated by maternal depressive symptoms (Yang et al. 2018). Similarly, intimate partner violence impeded mothers’ well-being and ability to provide basic care and nurturance, leading to neglect (Nicklas and Mackenzie 2013). Parental substance use. Several studies have connected parental substance use and neglect – in early and middle childhood – in the general population of Quebec (Clément et al. 2016), in India (Esser et al. 2016), and among urban, low-income preschoolers (Manly et al. 2012). However, these findings have not been consistent; Mulder et al.’s (2018) meta-analysis did not find parental substance abuse to be linked to neglect. Cozza et al. (2018a) reported relations between parental substance use and physical neglect, moral-legal neglect, and educational neglect. In contrast, parental substance use was not associated with emotional and supervisory neglect. These relations appear to vary by neglect subtype. They may also be moderated by contextual factors (Freisthler et al. 2017) or by characteristics of the parental substance use (type, severity, dependence). Fathers. There has been growing attention to father-specific risk and protective factors for neglect. Fathers’ alcohol use, depression, parenting stress, employment, and Hispanic ethnicity were associated with physical neglect in young children (Lee 2013). Clément et al. (2016) identified specific risk factors for neglect, for fathers, stress related to reconciling work and family and, for mothers, stress related to child temperament, depression, and substance use. In contrast, positive father involvement lowered the risk of physical neglect (Lee 2013).

Child Factors Some may find it odd to consider how child factors may contribute to neglect. To be clear, the goal is not to apportion blame. Rather, it is to probe all in a child’s ecology that may contribute to neglect, including how individual-level characteristics may place certain children at risk. Findings related to child demographic factors in relation to neglect have not been consistent. Major studies have found different racial and/or ethnic patterns, finding higher overall neglect in non-White children (Mulder et al. 2018), or White US children (Vanderminden et al. 2019). One caveat is the importance of controlling for SES when probing the influence of race and ethnicity; this is often not done. Older child age was related to some subtypes of neglect, with few gender differences (Vanderminden et al. 2019). In a rural Chinese sample, boys and younger children were more likely to be neglected (Zhao et al. 2018). A particularly novel finding suggested a higher rate of neglect among sexual minority adolescents (i.e., those reporting non-heterosexual orientation; Donahue et al. 2017). Consistent with research reviewed in earlier synopses (Proctor and Dubowitz 2014), across studies, perinatal and child mental, physical, and behavioral problems

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were significant risk factors for neglect (Mulder et al. 2018). A case record review suggested particularly high risk of medical neglect among children with chronic medical conditions (e.g., spina bifida, cerebral palsy, asthma, obesity, HIV, diabetes) that demand burdensome, complex care (Parmeter et al. 2018). Attention-deficit/ hyperactivity disorder and internalizing problems (e.g., withdrawal) have been associated with neglect (Hadianfard 2014; Lansford et al. 2015). Parents may withdraw from children with internalizing problems such as depression and anxiety, leading to their neglect (Lansford et al. 2015). Of note, this relation seems to be reciprocal, with neglect also leading to internalizing problems in children (Christ et al. 2017). Parents of “difficult” children may be depressed, frustrated, or overwhelmed, thus contributing to neglect.

Summary Recent research has notably advanced our understanding of the etiology of child neglect. In particular, it has refined our understanding of societal-level factors beyond poverty contributing to neglect, such as internal migration and proximity of mental health services. It has identified parental cognitive, educational, and mental health factors malleable to clinical intervention and child-level risk factors such as internalizing problems and sexual minority status. Recent research has begun to elucidate important differences in the etiology of neglect subtypes. There have been advances in probing mediating pathways, with research showcasing the importance of parental mental health for example in etiological pathways to neglect (Nicklas and Mackenzie 2013; Yang et al. 2018). However, much remains to be learned. Elucidating mechanisms leading to neglect is a priority to improve prevention. It is important to recognize the role of strengths or protective factors that are often present and help buffer the influence of risks. Clinically, these offer valuable ways to engage constructively with families to help improve their functioning and care of children. Protective factors may reside within a family and its members, such as positive father involvement in a child’s life (Lee 2013) and a parent’s ability to cope with the burdens of poverty or his child’s medical condition. Alternatively, they may be external to a family, such as the care provided by a professional or public policies that support families and parents (e.g., childcare subsidies; Maguire-Jack et al. 2019). In general, knowledge of protective factors regarding neglect remains “neglected.”

Prevention and Intervention Research, together with clinical experience, has guided efforts to prevent and intervene in child neglect. Here too much remains to be learned. Recent insights into neglect’s etiology have yet to be fully translated into prevention. The political will and resources too need to be harnessed to better address neglect. For example,

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there is a need to improve the training of healthcare and child welfare professionals on recognizing and addressing neglect (Colgan et al. 2018; Delong-Hamilton et al. 2015). Perceptions that neglect is less serious than other forms of maltreatment or that it is “just poverty” may prevent appropriate intervention and referral for needed services (Font and Maguire-Jack 2020; Read et al. 2018; Stokes and Taylor 2014). Programs to prevent neglect in older children, including adolescents, are also badly needed (Hicks and Stein 2015). For example, programs such as multidimensional family therapy may be adapted to prevent neglect in at-risk or indicated cases (Liddle et al. 2001). It is important to note that this chapter is concerned with research regarding neglect and not with what has been learned through clinical experience. Thus, principles for good practice concerning neglect are often based on a different kind of evidence.

Societal-/System-Level Prevention Policies and programs providing basic support to families, including child welfare services, may prevent neglect at the macro level. US programs include the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the Supplemental Nutrition Assistance Program (SNAP), Medicaid, the State Children’s Health Insurance Program (SCHIP), Head Start, Temporary Assistance for Needy Families (TANF), Social Security, Workers’ Compensation, and healthcare coverage under the Affordable Care Act. Limited research has examined the impact of these policies on child neglect, with researchers calling for greater attention to this area (Bullinger et al. 2019). A study of the economic recession of 2008 (Albert and Lim 2018) found that cash assistance received from Temporary Aid for Needy Families programs was associated with decreased neglect in many states. Access to childcare subsidies appeared to prevent neglect (Maguire-Jack et al. 2019). Finally, a raised minimum wage was associated with reduced neglect reports (Raissian and Bullinger 2017). Some reforms in child welfare systems have been enacted to better address neglect (Lacharite2014; Long et al. 2014). In the USA, Differential Response, a tiered multitrack approach that allows for greater flexibility in responding to maltreatment reports (i.e., to Investigative or Alternative Response tracks), has been increasingly implemented (Fluke et al. 2019). Alternative Response is a fundamentally different, potentially more constructive approach to identifying and addressing a family’s needs than a traditional, forensically oriented CPS investigation. It has typically been used for cases involving neglect and less severe physical abuse. A recent study showed fewer re-reports in counties utilizing Differential Response, although re-reports were higher within just the Alternative Response group relative to the Investigative Response group (Fluke et al. 2019). Clearly, Alternative Response may work better for some families than others. There is always the option of reverting to the Investigative Response approach if needed. More research is needed to understand the outcomes of these approaches.

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Family-Focused Prevention Home Visiting and Group Models. Effective neglect intervention and prevention must also engage at the levels of the family and individuals. Group-based parent training programs such as the Incredible Years have been effective at promoting case closures among families with neglect (Sicotte et al. 2018). Home visiting programs such as the Nurse-Family Partnership and Triple-P are well-known general maltreatment prevention programs, with evidence of specific effects on neglect (Avellar and Supplee 2013; De Graaf et al. 2008; Lee et al. 2018; Prinz et al. 2009; Zielinski et al. 2009). One notable study suggested particularly strong long-term preventative effects of Nurse-Family Partnership on neglect versus other maltreatment types (Zielinski et al. 2009). In a scaled-up home visiting program, overall maltreatment reductions were completely explained by neglect (Chaiyachati et al. 2018). Similarly, child welfare-involved mothers receiving home visitation showed substantial decreases in re-reports of maltreatment, including neglect (Lee et al. 2018). In contrast, another study found home visiting to be associated with less physical abuse but not neglect (Guterman et al. 2013). SafeCare is a well-researched, in-home training program largely implemented by caseworkers for parents of children ages 0–5 who have been reported for or are at risk for neglect or physical abuse. In a large randomized trial, SafeCare reduced rereports of neglect and abuse among CPS-involved children (hazard ratios 0.74–0.83) and improved parent’s depression and parenting skills (Chaffin et al. 2012). Recent studies concerned the dissemination of SafeCare, including its implementation within complex systems and its sustainability (Gallitto et al. 2017; Weegar et al. 2018). SafeCare has been adapted internationally, with initial findings suggesting feasibility (Arruabarrena et al. 2019; Oppenheim-Weller and Zeira 2018). SafeCare has also been adapted in a program specifically targeting fathers called SafeCare Dads to Kids (D2K); early findings suggest feasibility but no effect on neglect (SelfBrown et al. 2017, 2018). Primary Healthcare Model. The Safe Environment for Every Kid (SEEK) model takes advantage of regular healthcare visits for 0–5-year-olds and the generally positive relationships between parents and primary healthcare professionals (Dubowitz 2014). It involves training professionals, screening for major risk factors for neglect (and abuse), and providing parents with support, psycho-education, and referrals to community resources. In a randomized controlled trial involving a high-risk sample, families receiving SEEK had fewer CPS reports, fewer instances of medical neglect and delayed immunizations, and fewer parental self-reported physical assaults, compared with those receiving standard primary care (Dubowitz et al. 2009). In a second trial involving a relatively low-risk sample of middle-income families, mothers in the SEEK group reported less psychological aggression and fewer minor physical assaults compared with the comparison group (Dubowitz et al. 2012). SEEK required no additional time on average from health professionals and was estimated to be cost saving (Dubowitz 2014).

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Models for Co-occurring Neglect and Parental Substance Abuse. Other programs have been developed for when neglect and parental substance abuse co-occur, a common phenomenon. A randomized trial of family-based behavioral therapy for mothers with substance abuse and reported to CPS for neglect found improvement in risk factors such as unemployment and HIV risk behaviors and less risk for maltreatment. However, these benefits were observed only among mothers reported for neglect without pre- or post-natal drug exposure (Donohue et al. 2014). The Families Actively Improving Relationships (FAIR) program for families involved with CPS simultaneously targets substance use and neglect. In a pilot study, mothers in FAIR were more likely to complete their treatment and to reduce their substance use, improve their parenting, and better meet their needs (Saldana 2015). Prevention of Impairments due to Neglect. A few interventions address the effects of neglect in children. The Attachment and Biobehavioral Catch-Up Intervention has been shown to enhance regulation (i.e., to achieve more normal cortisol production, higher early morning cortisol, and a steeper diurnal slope) among CPS-involved children at risk for further neglect (Bernard et al. 2015). The Fostering Healthy Futures program provided mentoring and skills training to preadolescent youth in foster care. It improved their mental health, including in those who had been severely physically neglected (Taussig et al. 2013).

Key Points Related to Child Neglect • Research on the etiology of neglect has advanced significantly. It has shown societal, family, parent, and child contributors to neglect, with particularly strong evidence provided through meta-analyses. • Societal-level factors, such as internal migration, and local structures, such as proximity to mental health services and crime, have been connected to neglect. • Research on the etiology of specific neglect dimensions (i.e., subtypes, chronicity, timing, and severity) has begun to emerge with additional development needed. • Mediation studies have elucidated pathways in the etiology of neglect, for example with parental mental health mediating pathways between violence exposure and neglect. However, many potential pathways remain unexplored. More research on mechanisms should be prioritized given their value for informing prevention. • Some research has examined neglect as it specifically pertains to fathers and on protective factors for neglect, but there is a need to further develop these areas. • Prevention and intervention strategies have been studied with much need for further development, evaluation, and dissemination. Family-focused prevention models have the strongest evidence base overall, but even within this category very little has been done pertaining to children over 5 years of age. • Research in societal- and system-level interventions remains emergent. Much opportunity remains to learn about how policies and system-level interventions may reduce neglect.

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Summary and Conclusion In conclusion, there have been valuable advances in neglect research. Recent studies have refined our understanding of predictors of neglect, at multiple levels of the social ecology. Knowledge invariably needs to be strengthened and applied. The etiological literature still largely concerns neglect in general, rather than specific neglect dimensions. Societal-level predictors of neglect continue to be overshadowed by a focus on family- and parent-level predictors. Finally, there is a great need to expand knowledge on pathways leading to neglect. The “neglect of neglect” in the areas of prevention and intervention research is a persistent problem. There is a need to recognize advances in research on the etiology of neglect and to translate this knowledge to practice. General maltreatment programs inconsistently include neglect as a specific outcome. Programs targeting school-aged children and adolescents remain rare. The relative lack of development in neglect prevention and intervention may partly explain why neglect rates remain relatively stagnant compared to steep declines in physical and sexual abuse (Finkelhor et al. 2018). The development of prevention and intervention approaches and strategies should be a priority going forward, as should the dissemination of effective and promising interventions. In short, while notable progress in neglect research should be recognized and saluted, much work remains.

Cross-References ▶ Child Neglect ▶ Overview of Child Maltreatment ▶ The Nature of Neglect and Its Consequences

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Contents Introduction: The Historical “Neglect of Neglect” and Past Reviews . . . . . . . . . . . . . . . . . . . . . . . . . Definitions of Child Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conceptual Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Heterogeneity and Dimensions of Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Measurement and Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Incidence and Prevalence of Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cognitive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physical Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Biological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points Related to Child Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Neglect is the most common form of child maltreatment. Repeated calls have implored the scientific community to remedy the “neglect of neglect,” the paucity of research on neglect relative to abuse. Barriers to the advancement of scientific knowledge and to tackling this intractable public health problem include the

This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. J. M. Kobulsky (*) School of Social Work, College of Public Health, Temple University , Philadelphia, PA, USA e-mail: [email protected] H. Dubowitz School of Medicine, University of Maryland, Baltimore, MD, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_9

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difficulties defining neglect and less concern regarding its relative harm. Despite these challenges, numerous studies on the nature and consequences of child neglect have been conducted. Many of these have been published since major reviews last evaluated research on neglect. This review focuses on recent advances in research regarding child neglect’s nature, measurement, prevalence, and consequences. It is guided by the question: What is new about neglect? Although much work remains to be done, noteworthy advances have been made. Keywords

Child neglect · Definitions · Prevalence · Effects · Measurement · Assessment

Introduction: The Historical “Neglect of Neglect” and Past Reviews Approximately 35 years have passed since the first alert to the scientific community regarding the “neglect of neglect,” the inattention to child neglect research despite its prevalence (Wolock and Horowitz 1984). Researchers have continued to note the relative dearth of knowledge on child neglect, and multiple calls to action have been made to remedy this gap (Widom 2013; US Department of Health and Human Services [USDHHS] 1997). A comprehensive review by Proctor and Dubowitz (2014) examined nearly 30 years of literature on neglect through 2012. The purpose of the present review is to assess the current state of knowledge on neglect focused on research published between 2012 and 2019. In this chapter, we review recent literature on the definitions and nature of child neglect, its measurement/assessment, and its consequences. A second chapter in this volume focuses on the etiology of neglect and preventive and other interventions. We fully recognize that knowledge is also derived from clinical experience, a different kind of evidence helping guide good practice. These chapters, however, are limited to a consideration of research on child neglect.

Definitions of Child Neglect Neglect is often defined as omissions in care by parents or surrogates that constitute a failure to meet children’s basic needs, in contrast to abuse, acts of commission. A scientific consensus on one definition of child neglect however has proven elusive and may not be realistic. Different disciplines have inherently different approaches to neglect. A pediatrician may be concerned about a baby growing poorly due to inadequate food, whereas a prosecutor may be focused on criminal behavior. Another barrier is the relatively nebulous nature of neglect as the inadequacy of care versus discrete abusive acts. There is also a tension between focusing on parental behavior (and responsibility) or on children’s unmet basic needs or rights. In addition, neglect exists on a continuum from grossly inadequate to optimal care;

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the likelihood and severity of harm associated with various levels along this continuum are often difficult to gauge (Proctor and Dubowitz 2014). The lack of a clear definition to anchor neglect research impedes scientific progress, often precluding comparisons across studies.

Conceptual Considerations Variation in law. Definitions of neglect by states in the USA are guided by the federal Child Abuse Prevention and Treatment Act (CAPTA).These definitions thus apply especially to research based on child welfare policy and practice. The 2014 Institute of Medicine (IOM) and National Research Council (NRC) report provided this definition: “The failure of a parent, guardian, or other caregiver to provide for a child’s basic needs” (p. 21). However, US states vary widely in their legal definitions of neglect. Most include abandonment and failure to provide health care and adequate nutrition, supervision, and shelter, but they vary considerably regarding educational and emotional neglect and prenatal exposure to illicit substances (Rebbe 2018). Furthermore, states vary in whether they include religious exemptions (i.e., excusing omissions in health care based on religious beliefs), neglect caused by poverty, and actual as well as potential harm (Rebbe 2018). While actual harm standards offer relatively concrete, objective guidance, there is concern that such restrictive interpretations of CAPTA preclude child protection in many potentially harmful situations. Parent versus child focus. In contrast to the above, researchers have advocated for child-centered definitions of neglect, defined as circumstances when a child’s basic needs (or rights) are not adequately met, thus harming or jeopardizing a child’s health, development, or safety. This alternative definition prioritizes what is important for children and their experiences over parental responsibility or culpability (Proctor and Dubowitz 2014). Child-centered definitions of neglect draw from ecological perspectives, which recognize the often multiple, interrelated multilevel contributors to child well-being, many of which may be beyond parents’ control (e.g., poverty; Belsky 1993). Child-centered definitions allow for consideration of a greater spectrum of potentially harmful circumstances, not limited to those primarily due to parents’ omissions in care. Focusing on children’s needs offers a more constructive less blaming frame, one that may better resonate with parents, facilitating their engagement in services. This does not imply that the parental role should be ignored (Proctor and Dubowitz 2014). A child-centered definition of neglect is supported by evidence of contributors beyond parents’ control, including structural and environmental factors (e.g., the availability of drugs in a community) to neglect (Freisthler et al. 2017). In addition, there has been recognition of bureaucratic neglect (e.g., the failure of the child welfare system to meet children’s needs) as well as societal neglect (e.g., a wealthy society that fails to ensure access to health care for all children; Yang and Ortega 2016). It is also important to consider neglect in indigenous communities in the context of historical trauma, including the legacy of colonization and forced

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removals of children from their families, another view supporting a child-centered definition (Newton 2018). A phenomenon that exists on a continuum. Care naturally occurs on a continuum, and the gray zone is large. It is difficult to establish specific cut points at which inadequate care becomes neglect or likely to cause harm. For many problems such as not having enough food, it is tricky to pinpoint when a threshold is crossed (e.g., inadequate food on a regular basis, lack of specific nutrients, or experiencing hunger). Currently, varying thresholds are used to indicate child neglect in research, contributing to inconsistent findings. Child’s development level. There is a long-standing consensus on the need for developmentally sensitive definitions of neglect. Children’s needs for care vary greatly over the course of their development, and there are naturally individuallevel differences among children. Recent studies have begun to consider what constitutes neglect during adolescence (Kobulsky et al. 2019b). More than younger children, adolescents’ dual, competing needs for independence and parental nurturing, monitoring, emotional support, and protection require consideration in conceptualizing neglect. The blurred responsibilities of adolescents and their parents may allow for the normalization of potentially persistent, damaging situations (e.g., routinely not intervening if the adolescent rather than the parent is held responsible for the inadequate care; Hicks and Stein 2015). Moreover, potentially neglectful situations that are unique to adolescents, such as having significant caregiving responsibilities for younger siblings or parents, should be considered in terms of their development and needs (Hicks and Stein 2015), as well as the cultural context. Beyond the poles of early childhood and adolescence, what constitutes neglect during different developmental periods may be unclear. A recent study of experts aptly illustrates this point, demonstrating the difficulty in defining a specific age at which children can be left home alone (Jennissen et al. 2018). Nearly all experts considered leaving a 4-year-old home alone neglectful but not a 14-year-old; 88%, 48%, and 4%, respectively, considered leaving a child 8, 10, and 12 years old home alone neglectful, respectfully (Jennissen et al. 2018). In addition to development, there are multiple other considerations regarding children left home alone: child’s physical and mental health, duration of time left alone, time of day or night, presence of nearby support, and the nature of the neighborhood. This raises the importance of context. Social context and culture. Neglect becomes even more difficult to define when taking a multicultural or international perspective (Lansford et al. 2015). Some scholars contend that the very concept of child neglect is biased by Western ideas, prioritizing nuclear family structures and parental versus community responsibility for the child (Laird 2016). Their contentions are mainly with parent-centered versus child-centered definitions of neglect. The difficult circumstances of many families (e.g., inadequate access to health care) do need to be considered, rather than simply and solely blaming parents for conditions that may be beyond their control. In subSaharan Africa, the lack of education and economic resources for ensuring child safety contributes to injuries from burns and falls (Laird 2016). In another example, having an adolescent (or child) take care of younger siblings may be a necessity for

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low-income families but irresponsible in other contexts. Missed educational opportunities due to such arrangements may also vary by society, particularly for girls. In response to these myriad circumstances, researchers in one international study defined neglect based on children’s perceptions that their parents did not pay attention to them and the things that were important to them (Lansford et al. 2015). Children’s needs partly depend on the demands of adulthood, which vary by society and culture. For example, the education and skills needed for a living wage job in the USA are considerably higher than in rural parts of a low-income country. In another example, the risks and benefits of “free-range” parenting, which emphasizes fostering children’s autonomy and sense of responsibility, need to be viewed in the context of the family and community culture. In contrast, “helicopter” parenting emphasizes vigilance and protection; this may unintentionally foster dependency and fearfulness (Pimentel 2012). These parenting approaches vary within and across cultures. Ultimately, children’s needs are largely individually determined, although a remarkable degree of common ground exists. This is demonstrated by the international consensus regarding the needs of children in the United Nations Convention on the Rights of the Child (United Nations General Assembly 1989) and in a study of indigenous communities (Newton 2017). Bias and perceptions. Biases may shape perceptions of neglect. Racial bias in perceptions of neglect has been documented, with caseworkers more likely to perceive a scenario featuring a Black baby (96%) as neglected than a White baby (94%, Ards et al. 2012). Gender may also affect perceptions of neglect. For example, in one study, laypersons were more likely to perceive a situation as neglectful if the gender of the parent and child in vignettes matched (Dickerson et al. 2017). Another study found that neglect was less often attributed to fathers than mothers (Kobulsky and Wildfeuer 2019). This likely reflects higher caregiving expectations of mothers. On the other hand, when neglect was attributed to fathers, it more often resulted in a criminal investigation (Kobulsky and Wildfeuer 2019). This may indicate a less forgiving attitude (i.e., more criminalization) when neglect is attributed to fathers. These biases underscore the fallibility of considering neglect through a parentblaming lens and the importance of a child-centered approach. Youth may have different views from parents and professionals in what constitutes neglect, with youth perceiving a wider spectrum of neglectful scenarios. For example, youth considered parental failure to provide emotional sensitivity as potentially neglectful (Hicks and Stein 2015). Youth similarly considered favoring siblings or prioritizing partners over children as potentially neglectful (Hicks and Stein 2015). The meaning and cognitive appraisal of the experience influence the potential effect on the youth. And, this would be influenced by the relationship of the responsible party to the child and other sociocultural and contextual factors.

The Heterogeneity and Dimensions of Neglect Neglect varies by subtype, chronicity, frequency, developmental timing, severity, cooccurrence, the relationship of the responsible party to the child, and context. Some

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of these have already been addressed. Most definitions recognize neglect to be a multidimensional phenomenon, but there are a variety of typologies. Subtypes. The IOM and NRC report (2014) specified that neglect may be physical (failure to provide food, shelter, or supervision), medical (failure to provide medical or mental health treatment), educational (failure to educate a child or attend to educational needs), or emotional (inattention to emotional needs, failure to provide mental health care, or permitting child to use alcohol or drugs). Other typologies combine medical and physical neglect or emotional neglect and emotional abuse (Barnett et al. 1993; Sedlak et al. 2010). Some separate physical and supervisory neglect or moral-legal neglect (e.g., exposing a child to illegal activity or other activities that promote delinquency) and emotional neglect (Barnett et al. 1993). Neglect subtypes are largely based on tradition and are not necessarily supported by empirical research. For example, a confirmatory factor analysis found evidence for physical, supervisory, and emotional neglect but not for educational neglect as a distinct subtype among 12- and 14-year-olds (Dubowitz et al. 2011). An exploratory and confirmatory factor analysis suggested five subtypes for adolescent neglect: inadequate monitoring, inattention to basic needs, permitting misbehavior, exposure to risky situations, and inadequate support (Kobulsky et al. 2019b). Clearly, subtypes of neglect can often co-occur. Chronicity and frequency. Chronicity is an important aspect of neglect. Neglect is usually considered to be a problem only when there is a chronic pattern; sporadic lapses in care are less likely to be viewed as neglect (Logan-Greene and Semanchin Jones 2015). Likewise, chronic abuse can be construed as neglect (e.g., sexual abuse that is long ignored). Many situations only become harmful when there is a pattern of omissions in care. Some single lapses, however, can be fatal, such as an infant left unattended in a bathtub and missed medical care for children with certain medical conditions (Okun 2017). The frequency or recurrence of neglect experiences, such as measured by CPS referrals, is sometimes used as a proxy for chronicity (Jonson-Reid et al. 2019). However, while chronicity implies persistence over an extended period, frequency simply refers to the number of known instances. Timing of neglect. Experiences of neglect may have varying salience depending on when they occur in relation to a child’s development. For example, a father’s absence may be far more difficult for a 10-year-old boy compared to a 4-year-old. Similarly, a mother’s unresponsiveness to an infant’s cues due to postpartum depression likely has different impact compared to an older child. One recent study found that of three classes of neglect (chronic, late [i.e., middle or late adolescent onset] and limited), the late neglect group had the highest risk for young adult substance use and related problems, suggesting the importance of developmental timing (Dubowitz et al. 2019a). Severity. The severity of neglect varies considerably from circumstances that are questionably harmful to others that are fatal. Severity concerns potential or actual harm and the seriousness of the consequences. For example, neglect resulting in occasional hunger due to missed meals is clearly less severe than neglect resulting in stunting or wasting due to severe malnutrition. Potential harm is important given an interest in preventing harm. A challenge regarding potential harm is estimating the

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likelihood and seriousness of outcomes, in the short and long term. For example, leaving a toddler in the care of an older, preadolescent child for a short period may be perceived to be less severe than leaving this child in the care of a known abuser. Moreover risk varies depending on the child and circumstances. For example, a mature 8-year-old may manage adequately being home alone after school. A child this age who is involved in setting fires presents a different risk. Child welfare policies in the USA tend to capture only the more severe circumstances for substantiating neglect (Proctor and Dubowitz 2014). An advantage of a child-focused definition is that less severe circumstances (e.g., an unimmunized child) may still be addressed, without necessarily involving CPS. Co-occurrence. Clearly, neglect frequently co-occurs with other forms of maltreatment and other adversities, such as exposure to community violence and poverty. In addition, children may experience more than one subtype of neglect. Patterns of co-occurrence vary by study samples, measures, and the adversities studied (Debowska et al. 2017). Research may focus on cumulative adversity or the similar construct, poly-victimization. One study found that physical and supervisory neglect was strongly linked to other forms of victimization (Turner et al. 2019). Physical neglect was strongly associated with physical and sexual abuse, as well as economic stressors; supervisory neglect was associated with victimization by non-relatives.

Measurement and Assessment The challenges in defining neglect have implications for its measurement and assessment. For research purposes, neglect may be measured by CPS reports, parent or child self-reports, reviews of medical records, and direct observation. Each method has advantages and shortcomings. CPS reports are limited to instances that have been identified, reported, screened, and investigated, with bias a concern, and these reports are also susceptible to varying assessment, laws, and policies. Selfreport of neglect may be particularly prone to recall error and social desirability (Compier-de Block et al. 2017). Medical records generally capture very limited aspects of children’s experiences. Videotaping and coding behavior and home observations, such as adequacy of food and presence of hazards, are labor intensive. Both may also be hampered by the Hawthorne effect (i.e., behaving differently when watched). To partly circumvent the limitations of any one measure, information from different measures and sources may be integrated. Among the most prominent self-report measures of neglect have been Straus’ Multidimensional Neglectful Behavior Scale and its derivations (Dubowitz et al. 2011; Kobulsky et al. 2019b; Straus et al. 1995). These measures capture multiple dimensions and key characteristics of neglect and its subtypes and have known psychometric properties (Dubowitz et al. 2011; Kobulsky et al. 2019b). Another is the Child Neglect Questionnaire, a 46-item measure that incorporates both parents’ and children’s perspectives (Stewart et al. 2015). Results supported physical, emotional, educational, and supervisory neglect dimensions, with discriminant,

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concurrent, and predictive validity (Stewart et al. 2015). Other measures include neglect together with other forms of maltreatment. For example, the Maltreatment and Abuse Chronology of Exposure Scale includes retrospective self-report of the timing of physical and emotional neglect; these subscales had adequate test-rest reliability and convergent validity (Teicher and Parigger 2015). Although practice guidelines exist for the clinical assessment of neglect (DePanfilis 2006), little research has been done in this area. Unclear definitions, time constraints, and lack of training complicate the screening for and assessment of neglect in practice settings (Delong-Hamilton et al. 2015). The Graded Care Profile 2 (GCP2) is a practical assessment tool of neglect in four domains: physical care, care and safety, emotional care, and developmental care (e.g., stimulation; Johnson and Fisher 2018). It is designed to help social workers, home visitors, and other professionals know when to provide referral, prevention services, or more intensive intervention. The tool was recently found to be reliable and valid in centers serving neglected children in England (Johnson and Fisher 2018). The Rapid Assessment of Supervision Scale (RASS) is a clinical decision-making tool for the assessment of supervision of young children; it has been shown to predict injury (Anderst et al. 2015). Similar efforts are underway, such as the initial Signs of Neglect in Infants Assessment Scale (SIGN; Arimoto and Tadaka 2019).

Incidence and Prevalence of Neglect Estimations of the incidence or prevalence of neglect clearly depends on definitions and assessment methods. Neglect is by far the most common form of maltreatment reported to CPS in the USA, typically comprising 75% of reports investigated and involving 7 per 1,000 children in 2017 (US DHHS 2019). Reports of neglect were four times more common than of physical abuse and nearly nine times more common than of sexual abuse (US DHHS 2019). By age 17, 25% of youth in the USA have had a CPS neglect report, with substantially higher rates among Black youth (Kim et al. 2017). Studies outside of the USA have similarly shown neglect to make up more than half of CPS reports (Braham et al. 2018). Prevalence studies based on self-report are important because neglect is often not reported to CPS (Sedlak et al. 2010). A meta-analysis of studies based on survey and interview methods found a prevalence of 16% for physical neglect and 18% for emotional neglect (Stoltenborgh et al. 2013). More recently, the National Survey of Children’s Exposure to Violence found 15% of children 0–17 years had experienced lifetime neglect and 6% in the past year (Vanderminden et al. 2019). A Canadian study found a somewhat higher annual incidence of neglect: 26% for children aged 6 months to 4 years, 29% for those aged 5–9 years, and 21% for the 10- to 15-year-olds (Clément et al. 2016). The paucity of studies on the prevalence of neglect outside of North America has been noted (Stoltenborgh et al. 2013). Recent analyses have begun to remedy this situation, often using the International Society for the Prevention of Child Abuse and Neglect’s (ISPCAN) Child Abuse Screening Tool (ICAST; for review see Kobulsky

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et al. 2019a). However, studies of low- and lower-middle income countries remain rare. A large study (n ¼ 41,194) of Balkan countries identified rates of neglect ranging from 23% (lifetime) and 17% (past year) in Romania to 48% (lifetime) and 20% (past year) in Bosnia (Nikolaidis et al. 2018). Rates as high as 94% of children exposed to emotional neglect and 89% to physical neglect were found in Burundi, a country severely affected by civil war and political violence (Charak and Koot 2014). These rates were three to four times higher than in Canadian, German, and South Korean samples (Charak and Koot 2014). Of note, rates of physical and sexual abuse have declined dramatically in the USA since 1990, by 53% and 65%, respectively (Finkelhor et al. 2018). In contrast, the rate of neglect has declined by only 12%. The reasons for this only modest decline are likely complex. They may include lack of attention to neglect and the related difficult circumstances faced by many families (Finkelhor et al. 2018).

Consequences In addition to establishing its prevalence, recent research has portrayed the significance of child neglect by advancing knowledge on how it results in various forms of harm (Table 1). Notable advancements include systematic reviews and studies probing mediating and moderating influences of neglect on its outcomes. Outcomes have included relatively proximal (i.e., short-term, direct) and distal (i.e., long-term, indirect) effects of neglect. They include cognitive, mental health, and physical health outcomes throughout the lifespan as well as biological effects. Knowledge of the effects of specific neglect subtypes remains relatively undeveloped, as does the effect of neglect during specific developmental stages.

Cognitive Research has continued to show neglect’s detrimental effects on cognitive outcomes, including IQ, achievement test scores, reading ability, perceptual reasoning, and academic performance – from early childhood through adulthood. We focus on systematic reviews in our summary of recent literature. Preschool. Studies have identified cognitive effects of neglect or emotional abuse in preschoolers (Naughton et al. 2013). Specifically, infants with neglect and failure to thrive had lower cognitive performance; neglected infants with depressed mothers had language delays. There were, however, no differences in play complexity and cognitive play among those 0–20 months. Memory delays have been found in toddlers aged 20–30 months and language delays in children aged 3–5 years. In children aged 4–5 years, neglect was associated with lower cognitive functioning, less involvement in tasks, less creativity, and difficulty discriminating emotional expressions of peers. Lower overall intelligence in neglected children aged 5–6 years was also identified (Naughton et al. 2013).

Mental Health • depressive, anxiety, eating and behavioral/ conduct disorders • suicidal behavior and attempts • risky sexual behavior, sexually transmitted infections (STIs) • psychological maladjustment, hostility or aggression, emotional dysregulation, lower emotional responsiveness, negative worldview School-Aged Children • dependence or defensive independence • lower general intelligence and IQ, intellectual • poor self-esteem and low self-efficacy performance, numeracy, language and literacy • substance use skills; impaired language development and Infancy/Preschool cognition • insecure-avoidant and insecure-disorganized • impaired executive decision-making attachment; withdrawn and avoidant behavior • disciplinary problems, suspensions, grade • social difficulties retention and more special educational needs • negativity in play • lower emotional knowledge • disruptive behavior, aggression, conduct • better problem solving, abstraction and problems planning • emotional dysregulation Adolescence • poor self-esteem • less cognitive flexibility School-Aged Children • deficits in interpreting emotions • school dropouts, school adjustment problems, • internalizing behavior problems, attention deficit hyperactivity disorder, coping problems, less academic competence emotional dysregulation Adulthood • poor self-esteem • lower IQ • externalizing behavioral problems deficits in interpreting emotions • less prosocial behavior • less educational attainment, employment

Cognitive Development Infancy/Preschool • lower cognitive functioning • memory delays • language delays • less involvement with tasks and less creativity • lower overall intelligence • deficits in interpreting emotions

Table 1 Summary of Consequences of Neglect Identified by Research 2012–2019

Adulthood • ischemic heart disease, migraine headaches and arthritis • obesity

Physical Health Childhood/Adolescence • dental caries • injury and fatality

Biological • reduced cortical thickness in prefrontal, parietal and temporal lobes • lower hippocampal volume (males) • altered white matter connectivity • heightened amygdala activity and differences in functional coupling of amygdala and medial prefrontal region when viewing emotional facial expressions • differences in activities of the brain associated with executive control • elevated cortisol • epigenetic modulations in genes

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Adulthood. • major depressive disorder, dysthymia, posttraumatic stress disorder, psychopathy, nonsuicidal self-injury, psychopathology • substance use and severe withdrawal symptoms • risky sexual behavior • violence perpetration and victimization • eating disorders

Adolescence. • depression, post-traumatic stress, anxiety, sexual concerns, anger, dissociation, sleep disturbances • aggression and delinquency • sexual risk taking • smartphone addiction • victimization • externalizing problems • substance use

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School-aged children. Another systematic review of neglect or emotional abuse in school-aged children (5–14 years old) suggested that neglect led to inferior general intelligence, executive decision-making, intellectual performance, and numeracy, language, and literacy skills (Maguire et al. 2015). More disciplinary problems, suspensions, grade retention, and special educational needs have been observed among neglected children, as well as deficits in emotional knowledge (ability to identify and understand emotions; Maguire et al. 2015). In children age 3–10 years, neglect was associated with impaired cognitive and language development (Spratt et al. 2012). However, in one study, neglected children were found to have better problem-solving, abstraction (identification of a common relationship or feature in a series), and planning abilities than non-maltreated children; although unexpected, this is consistent with children being left alone to deal with their environment (Maguire et al. 2015). Adolescence and adulthood. In adolescence, physical neglect has been associated with decreased cognitive flexibility, an executive function that involves the ability to shift thinking from one concept to another (Spann et al. 2012). Deficits in interpreting emotions have been demonstrated among neglected adolescents and adults (Doretto and Scivoletto 2018). Other studies found emotional neglect to be associated with difficulty identifying feelings and recognizing emotional cues, with low IQ mediating this relation (Cahall Young and Widom 2014). Importantly, neglected children who lived in a stable environment for longer periods of time had higher IQ scores compared to those with less stability (Spratt et al. 2012). One challenge in synthesizing research is that studies vary in whether they compare neglected children to non-maltreated or abused children. Some studies have pointed to its detrimental influence on school dropouts, but not on academic performance and school engagement, relative to maltreated youth (Naughton et al. 2017). Other studies have associated neglect with school adjustment problems in South Korean adolescents, with direct and mediated effects via emotional/behavioral problems and impaired academic competence, peer attachment, and self-esteem; these relationships tended to be stronger and more consistent than those related to physical and emotional abuse (Lim and Lee 2017; Oh and Song 2018). Another study identified associations of neglect and lower rates of high school graduation and employment stability (Font and Maguire-Jack 2020). The latter finding was more significant for neglect than for abuse. In sum, neglect appears clearly related to impaired cognitive and academic functioning, although many studies do not account for other adversities often associated with neglect. Certain mediators, such as peer attachment and emotional and behavioral problems, offer useful pointers for interventions to help ameliorate the harms associated with neglect. Likewise findings that stability in the environment may buffer effects of neglect offer important direction for developing interventions.

Mental Health Research has demonstrated the relation between neglect and attachment and an array of mental health problems throughout the life course. Across studies, neglected youth are at two to three times higher risk for depressive, anxiety, eating, and

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behavioral/conduct disorders, with a dose-response relationship for depressive disorders (Norman et al. 2012). Broad relations between neglect and suicide attempts, risky sexual behavior, sexually transmitted infections (STIs), drug use (but not substance abuse), and “non-problem” alcohol use are evident (Norman et al. 2012). Research has also attempted to disentangle the relative effects of abuse and neglect on mental and behavioral health. Some studies have suggested stronger effects of abuse (physical, sexual, or emotional) relative to neglect alone on aggression, anxiety, and posttraumatic stress disorder (Augusti et al. 2018). However, other research has found that neglect had equivalent or stronger effects on such outcomes (Vachon et al. 2015). In addition, research has demonstrated the effects of neglect to extend beyond those attributable to poverty (Font and Maguire-Jack 2020). Studies on neglect and mental health have also been conducted in countries other than in North America (Khaleque 2015). Overall, these have similarly shown harmful effects of neglect on children’s psychological adjustment, hostility/aggression, dependence or defensive independence (e.g., not accepting help when needed), self-esteem, self-efficacy, emotional stability, emotional unresponsiveness, and worldview. These studies suggest robust effects of neglect across cultures (Khaleque 2015). Preschool. Research has shown the effects of neglect on age-specific groups throughout the lifespan. One systematic review of neglect combined with possible emotional abuse described associations with insecure-avoidant attachment, insecuredisorganized attachment, and passive and withdrawn behavior in infants and toddler aged 0–20 months (Naughton et al. 2013). Toddlers aged 20–30 months exhibited more negativity in play as well as avoidant behaviors. Children aged 3–4 years had more negative affect in their play. Those aged 4–5 years had social difficulties, withdrawn behavior, disruptive behavior, aggression, emotional dysregulation, and conduct problems. Five- to 6-year-olds manifested problems with self-esteem, peer relations, insecure-avoidant attachment, dissociation, and rule-breaking behavior. Throughout the preschool years, longitudinal studies have found transitions from ambivalent-insecure attachment to avoidant attachment, from passivity to anger and avoidance, from behavior problems to difficulties in peer relations, and lower selfesteem (Naughton et al. 2013). School-aged children. Another systematic review of school-aged children that included emotional abuse found multiple problems associated with neglect, including internalizing behavior, attention deficit hyperactivity disorder, coping and social skills, self-esteem, and emotion regulation (Maguire et al. 2015). With less consistency, effects of neglect in this age group appear to also involve externalizing problems and less prosocial behavior (Maguire et al. 2015). These relations may be influenced by other contextual factors such as community violence (Manly et al. 2012). Indeed, many of the effects associated with neglect may interact with other co-occurring adversities. Protective factors may also influence the effects of neglect; in a Chinese sample, sibling relationships were found to buffer effects on children’s internalizing problems (Wong et al. 2019). More research is needed on protective factors buffering the effects of neglect (e.g., positive father involvement; Dubowitz et al. 2019b).

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Adolescence. School-neglected children in Tanzania were found to have internalizing and externalizing problems in 6–9-year-olds, but not in the 10–15-year-olds (Hecker et al. 2018). However, another study found more consistent relations between neglect subtypes and trauma symptoms in 10–17-year-olds than in 2–9-year-olds (Vanderminden et al. 2019). A review of research on adolescents who had selfreported neglect or emotional abuse identified multiple problems, such as depression, posttraumatic stress, anxiety, sexual concerns, anger, dissociation, and sleep disturbances, but not low self-esteem (Naughton et al. 2017). Other research has suggested moderated effects, for example, neglect together with few peer relationships was associated with depression (Christ et al. 2017). Associations between neglect and suicidal ideation have been identified (Vanderminden et al. 2019). There have been mixed results regarding the association between substantiated neglect and externalizing problems in adolescents (Naughton et al. 2017). Selfreported neglect has been associated with aggression (Logan-Greene and Semanchin Jones 2015) and delinquency (Ryan et al. 2013). Neglect together with other forms of victimization, such as sibling violence, may aggravate the effect on delinquency (Van Berkel et al. 2018). Findings regarding the effect of neglect on adolescent substance use have also been varied (Naughton et al. 2017; Vanderminden et al. 2019). For example, overall lifetime neglect was associated with alcohol and illicit drug use, but some specific neglect subtypes (not being provided food, medical care, or shelter, hygiene neglect, parental incapacitation) did not predict illicit drug use, nor did past-year overall neglect predict alcohol and illicit drug use (Vanderminden et al. 2019). This relation may pertain to more severe substance use, such as early onset use or dependence. In one study, direct effects between neglect and earlier age of marijuana use were found (Proctor et al. 2017). This relation may also be indirect, mediated by internalizing problems, externalizing problems, and/or peer use (Dubowitz et al. 2016; Duprey et al. 2017; Proctor et al. 2017). The relation may also depend on contextual factors, such as neighborhood violence or the extent of maltreatment (Dubowitz et al. 2016; Duprey et al. 2017). Naughton et al.’s (2017) systematic review found evidence for sexual risk taking among neglected adolescents. However, in general, effects varied and depended on whether neglected youth were compared with non-maltreated or abused youth. One study identified anxious attachment as mediating the relation between neglect and number of sexual partners and avoidant attachment as mediating the relations between neglect and number of sexual partners, casual sexual behavior, and, in boys only, age of first intercourse (Thibodeau et al. 2017). Neglect has been associated with adolescent smartphone addiction, mediated by poor relationships with teachers (Kwak et al. 2018). Finally, neglected youth are at risk for other forms of victimization, including later peer victimization (Vaughan-Jensen et al. 2018). Few studies have examined exposure to neglect specifically during adolescence. Chronic physical neglect persisting into adolescence appeared to increase aggression

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and delinquency, particularly in boys, with social problems mediating these relations (Logan-Greene and Semanchin Jones 2015). Likewise, ongoing neglect in teens involved in the juvenile justice system has been associated with continued offending (Ryan et al. 2013). However, in another study adolescent onset neglect had stronger associations with subsequent substance use than chronic and low level of neglect (Dubowitz et al. 2019a). Adulthood. Neglect has been associated with major depressive disorder, dysthymia, posttraumatic stress disorder, psychopathy, and non-suicidal self-injury in adults (Cahall Young and Widom 2014). Moreover, a study in Kenya, Zambia, and the Netherlands suggested that associations between neglect and psychopathology hold across cultures (Mbagaya et al. 2013). A systematic review, however, found inconclusive evidence of a relation between emotional neglect and adult eating disorders (Kimber et al. 2017). Neglect has been found to affect young adult substance use; in one study, drug use and abuse via compromised adolescent self-esteem (Dubowitz et al. 2019a; Oshri et al. 2017). In one study, supervisory neglect predicted those with high-risk drinking patterns in early adulthood (Snyder and Merritt 2016). Childhood neglect may also complicate substance use treatment in adulthood, leading to stronger withdrawal symptoms (Francke et al. 2013). In addition, neglect has been associated with risky sexual behavior among young adults (Abajobir et al. 2018). Child neglect has also been associated with increased risk for the perpetration of child maltreatment and intimate partner violence (IPV) in adulthood as well as for victimization from IPV (Bartlett et al. 2017; Widom et al. 2014). Finally, neglect predicted incarceration in young adulthood, although this relation appears to be stronger for abuse (Font and Maguire-Jack 2020).

Physical Health The short-term physical health effects of neglect include dental caries, injury, and sometimes death (Brandon et al. 2014; Fisher-Owens et al. 2017). Indeed, about three-quarters of deaths attributed to child maltreatment involve neglect, most commonly due to inadequate supervision and involving primarily drownings and home fires (US DHHS 2019). Death may also result from deprivation (withholding food or water), medical neglect (failure or delay in obtaining necessary medical care), unsafe infant sleeping arrangements, and suicide (where the risk is not identified or addressed; Brandon et al. 2014). There is evidence that neglect can affect long-term physical health (Norman et al. 2012). For example, a systematic review identified effects of neglect on ischemic heart disease, migraine headaches, and arthritis, but not for hypertension, type 2 diabetes, obesity, asthma, ulcers, stroke, and neurological disorders (Norman et al. 2012). A more recent meta-analysis however linked physical but not emotional neglect and obesity (Danese and Tan 2014).

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Biological Studies have suggested biological mechanisms through which neglect may exert a deleterious and lasting influence on children’s cognition and health. These include neurological, neuroendocrine, genetic, and cellular mechanisms. Although much of this work remains preliminary, evidence of biological effects of neglect is quickly accumulating. Neurology. Functional magnetic resonance imaging (fMRI) research continues to suggest effects of neglect on brain size and function. However, most studies have not focused on neglect specifically, and several (e.g., the Bucharest Early Intervention Project; McLaughlin et al. 2014) focused on severely neglected institutionalized children such as those from Romanian orphanages. Attributing neurocognitive changes to neglect has been difficult because of frequently co-occurring adversities (McCrory et al. 2017). Widespread reductions in cortical thickness across the prefrontal, parietal, and temporal areas of the brain have been associated with neglect, which may help explain symptoms such as inattention and impulsivity (McLaughlin et al. 2014). Gender differences have also been suggested; one study showed that neglect was associated with less hippocampal volume in males but not females (Teicher et al. 2018). In boys, physical neglect alone was associated with altered white matter connectivity in areas of the brain involved in emotional expression and regulation and reward seeking (Tendolkar et al. 2017). These changes mediated the relation between physical neglect and trait anxiety, a personality dimension thought to underlie affect disorder. Other findings associated early neglect with more diffuse organization of prefrontal white matter, which in turn was linked to neurocognitive deficits (Hanson et al. 2013). Brain differences suggest effects of neglect on fear and reward processing systems. Studies using fMRI have consistently identified heightened amygdala activity in neglected individuals exposed to facial expressions (Doretto and Scivoletto 2018). In one study, emotionally neglected adolescents had higher amygdala reactivity, but only if they carried specific genetic polymorphisms (White et al. 2012). Hanson et al. (2013) found that emotional neglect was related to less rewardrelated striatal activity, which in turn was associated with depressive symptoms in adolescents. One study found differences in children and adolescents exposed to early institutional neglect in the functional coupling of the amygdala and the medial prefrontal region when viewing emotional faces (Gee et al. 2013). Specifically, patterns of more negative connectivity were seen in the younger children but not in the adolescents (Gee et al. 2013). Finally, fMRI studies have suggested differences in brain activities associated with executive control in institutionally neglected children (Mueller et al. 2010). Neuro-endocrine. The hypothalamic-pituitary-adrenal (HPA) axis is important for the stress response, with cortisol an end product of this system. Studies have found that neglected youth have elevated cortisol levels (Sullivan et al. 2013). This may signal disruptions in the neuro-endocrine and immune systems predisposing to health problems. Epigenetics (DNA methylation). Recent research has examined DNA methylation, an epigenetic process regulating gene expression, as a potential mechanism linking

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childhood neglect to health. In general, studies have associated child maltreatment with methylation of genes involved in the stress response or have shown such methylation to be associated with child and adolescent psychopathology (Barker et al. 2018). An investigation focused on neglect found that patterns of epigenetic modulations in genes of high-risk inner city 16–24-year-olds varied by type of maltreatment exposure, with some common patterns across maltreatment types and others differing for neglect (Cecil et al. 2016). Although the cross-sectional nature of this research and high rates of poly-victimization complicate the interpretation, it suggests that molecular mechanisms play a role in linking child neglect to later psychopathology. Importantly, in another study, emotional support attenuated effects of severe childhood physical and sexual abuse on methylation, suggesting that meeting children’s emotional needs buffers epigenetic effects (Shields et al. 2016). This last study is an example of research showing the possible reversibility of adverse outcomes, with intervention. Cellular aging (telomeres). Advanced aging at the cellular level as indicated by telomere length has also been associated with maltreatment, as well as various health outcomes, suggesting another mechanism through which neglect influences health. A rare case-controlled study that attempted to isolate neglect showed that a history of physical neglect predicted telomere length in adulthood, with greater differences associated with more severe physical neglect and among older individuals. No effects on telomere length were associated with other forms of maltreatment (Vincent et al. 2017).

Key Points Related to Child Neglect • Neglect definitions, particularly as they pertain to specific developmental periods, continue to be unclear. Child-centered definitions based on unmet needs or rights have advantages compared to assigning blame for child neglect. • Research has advanced significantly. It has demonstrated effects of neglect throughout the lifespan on cognitive, mental health, and physical health outcomes. Biological effects likely play a role in these outcomes. • Research has included many studies outside of the USA, although more information is needed about neglect in low- and middle-income countries. • Recent research has examined mediators and moderators of the effects of neglect and has included useful systematic reviews and meta-analyses. • Evidence has accumulated that the effects of neglect often differ from other forms of maltreatment, are distinct from poverty, and are often as pernicious as abuse. • There is a need for increased research attention to neglect dimensions (i.e., subtypes, chronicity, timing, and severity), including building empirical support for the dimensions and examination of their predictors and effects. • There is a need to build evidence of neglect as it pertains to distal outcomes (i.e., long-term physical health). Biological studies need to be replicated. • There is also a need to better elucidate the moderating and mediating influences to understand the pathways to different outcomes, to guide interventions. In particular, there is a need to further identify protective factors that may buffer the effects of neglect and contribute to resilience.

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Summary and Conclusion In conclusion, the short answer to the central question guiding this article “What is new about neglect?” is “a lot!” Unqualified statements regarding “the neglect of neglect” are no longer warranted as they were three decades ago (Wolock and Horowitz 1984). Notable scientific advances have been made regarding neglect’s nature, prevalence, and consequences. These advances include a growth of international studies and systematic reviews examining aspects of neglect throughout the lifespan. Cutting-edge research has probed effects of neglect on neurobiology, epigenetics, and cellular aging and has examined mediated and moderated pathways to and from neglect to elucidate underlying processes. In sum, studies convincingly portray neglect as a highly prevalent, menacing problem. They document neglects’ consequences on multiple domains throughout the lifespan, including biological, cognitive, mental health, and physical health. More research is still needed, of course, as well as in areas such as specific dimensions of neglect, the effects of neglect during different developmental stages, and the effects of neglect beyond childhood into adolescence and adulthood. Improved tools for measuring and assessing neglect throughout the developmental continuum are much needed to guide future research and clinical practice. Finally, much progress has been made, and much remains to be learned.

Cross-References ▶ Child Neglect ▶ Collecting Child Victimization Information from Youth and Parents: Ethical and Methodological Considerations ▶ Dental Neglect ▶ Neurobiological Consequences of Child Maltreatment ▶ Overview of Child Maltreatment ▶ Psychological Maltreatment of Children: Influence Across Development ▶ The Etiology of Child Neglect and a Guide to Addressing the Problem

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physical Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diagnostic Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nutritional Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Failure to Thrive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Severe Malnutrition and Fatal Nutritional Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Educational Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diagnostic Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emotional Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diagnostic Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diagnostic Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dental Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Autonomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Supervisory Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. S. Passmore (*) · L. Conway · M. Baxter School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA e-mail: [email protected]; [email protected]; [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_253

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Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 724 Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 724 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 724

Abstract

Neglect is the most prevalent form of child maltreatment in the United States. When intimate partner violence occurs in a home, neglect of the children is often present. The topic of child neglect encompasses physical neglect including nutritional neglect, medical neglect, educational neglect, emotional neglect, and supervisory neglect. Neglect is associated with poor neurodevelopmental outcomes and can result in language and communication delays and features resembling autism. Neglect can also cause lifelong physical and mental health problems. In this chapter we detail the types of neglect and what medical providers can look for in identifying neglect. Medical providers should evaluate all children from homes with intimate partner violence for signs of child neglect. Keywords

Physical neglect · Nutritional neglect · Medical neglect · Emotional neglect · Supervisory neglect · Educational neglect · Failure to thrive · Obesity

Introduction Neglect is the most pervasive form of child maltreatment accounting for about 75% of all maltreatment reports (Child Maltreatment 2017). However, the true numbers of neglect are likely underrepresented. Neglect does not generally get the same level of attention as child maltreatment, perhaps because of the insidious nature of neglect and the perceived lack of urgency (Dubowitz 1994). However, outcomes can be just as severe with neglect. Neglect accounts for approximately 75% of all child maltreatment deaths (Child Maltreatment 2017). Neurodevelopmental outcomes can be worse with neglected children as opposed to their abused counterparts (Dubowitz 1994). Neglect occurs when a child’s basic needs such as shelter, clothing, protection, and nutrition are not met. Under this childcentric definition, the inability to meet these needs may be attributed to the child, parent, caregiver, family, or community (Dubowitz et al. 2000). However, the application of this definition is variable depending on the evaluator, such as a medical provider, child protective services (CPS), law enforcement, etc., and the state in which it occurs. What is considered neglectful by a medical provider may not meet the threshold for neglect for a CPS investigation. Generally, neglect is an act of omission resulting in actual or potential morbidity or mortality, as opposed to the various forms of abuse, which are acts of commission. Neglect is further subdivided into the categories of physical, medical, nutritional, educational, supervisory, and emotional neglect.

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When evaluating neglect, a practitioner should consider the severity, chronicity, frequency, and context of neglect (Jenny 2011). Severity refers to the seriousness and likely harm associated with the event. A child left alone in a car on a summer day is at greater risk of harm compared to an infant left alone in a crib while a parent takes out trash. Chronicity refers to the needs of a child not being met over time. For instance, not brushing teeth once is not associated with significant harm, whereas the persistent lack of dental hygiene is associated with dental caries. Chronicity refers to the pattern of neglect. Previous involvement with CPS can be proxy for chronicity (Dubowitz et al. 2000). Frequency relates to the number of incidents of neglect. Intentionality evaluates whether the parent or caregiver is deliberately failing to meet the child’s needs. The context of the neglect refers to the lens through which neglect is evaluated. Cultural context and poverty are two such lenses. In some cultures, it is appropriate for young children to take responsibility for their younger siblings, but the age at which that is acceptable is not universally agreed upon in the United States. A medical provider should be culturally sensitive but also consider the safety and well-being of children. Poverty is also strongly linked with neglect. The presence of poverty brings many challenges to a family unit including food and financial insecurity, access to safe housing, and quality medical care among many others. These challenges can make providing care difficult for caregivers and thus at risk for neglect. However, the presence of poverty is not inherently linked with neglect as many families are able to provide adequate care for their children in the absence of robust financial resources (Laskey and Sirotnak 2019). It is often too simplistic to classify a situation as just neglect or not neglect. Neglect is a continuum with many interwoven factors. For example, the caloric needs of children differ depending on the age, social norms of acceptable household cleanliness are debatable, and the age of a child who can be left alone depends on the child’s development and level of independence. Simply put, neglect is not a black and white issue; gray areas must be explored. It is most helpful to evaluate concerns for neglect as a construct to determine whether there is an increased likelihood for morbidity or mortality. Some state statutes require actual harm to occur to a child in order to involve judicial intervention; however, other states allow for intervention with presence of the potential for harm. In a situation involving potential harm, the long-term effects may not be noticeable until sometime in the future (Jenny 2011). Children exposed to intimate partner violence (IPV), a subset of domestic violence, are at high risk of neglect. Intimate partner violence is a leading precursor of child maltreatment. Studies indicate that in 30–60% of homes where there is child maltreatment or intimate partner violence, the other is also occurring (Edleson 1999). The co-occurrence rate of physical abuse and IPV is 60% (Thackeray et al. 2010). In homes where intimate partner violence occurs in the first 6 months of a child’s life, that child is two times more likely to suffer neglect or psychological abuse until age 5 (McGuigan and Pratt 2001). Child neglect has lifelong consequences as identified in the Adverse Childhood Experiences study. Children exposed to IPV are at an increased risk of internalizing behaviors such as

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depression and anxiety. They are also at increased risk of externalizing behaviors such as attention difficulties and rule breaking. These children frequently have difficulty developing relationships and struggle academically. Unfortunately, these children are also at high risk of becoming abusive in their own relationships (Thackeray et al. 2010). Early identification and intervention are imperative to improve outcomes for victims. Application of a social ecological model allows for a framework to examine neglect through different contributing factors at the individual, relationship, community, and society level. The first level of this model involves the individual, either parent or child. A parent has to have the capability to provide for a child’s needs. A parent must have the financial, intellectual, and emotional capacity to provide care. Substance abuse, intellectual disabilities, and emotional health are maternal factors that have been correlated with neglect (Jenny 2011). The next level of the social ecological model involves the relationships between those living in the home. A healthy relationship between a parent and his or her partner, as well as a healthy relationship between a parent and child, is integral for the relationship level to be successful. Studies have shown that neglected children have more negative interactions with their mothers as compared to abused children (Bousha and Twentyman 1984). The next level of the social ecological model is the community. From a community standpoint, having resources in the community to support parents such as access to transportation, affordable child care, and food resources is protective against neglect. Extended family and friend support is also protective against child neglect. The final level, society, involves programming that is supportive of parents and families, such as maternity/paternity leave, and resource allocation to address poverty may decrease the incidence of neglect (Fig. 1).

Individual

Family

Community

Society

•Emotional Health •Substance Abuse •Intellectual Disabilities

•Lack of Support •Compromised Relationship of Mother-Child Dyad •Social Isolationism

•Lack of Quality Affordable Childcare •Lack of Access to Medical, Food, and Other Resources •Lack of Transportation

•Poverty •Lack of Family Centered Programming

Fig. 1 Social ecology: contributing factors to neglect

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Physical Neglect Introduction Physical neglect occurs when a child’s basic physical needs are not met and includes inappropriate shelter/housing and clothing, lack of appropriate hygeine and an overall safe envornment to thrive (Jenny 2011). Many definitions, including those used in research, include nutritional neglect and medical neglect as subcategories of physical neglect. In this chapter, each of these topics is discussed separately in more detail. Within surveys used for research, physical neglect meets more objective definitions as compared to other forms of neglect (Stoltenborgh et al. 2013). However, there are inherent flaws with data collected for neglect studies due to inconsistency in definitions used by researchers. For example, when defining how physical neglect occurs, there is debate whether neglect only happens when harm occurs or it is present with the potential for harm. This is important as it relates to how researchers and those working in child protective services from various jurisdictions define neglect (Mulder et al. 2018), which relate to variation in numbers of neglect cases. Another key aspect is from what viewpoint to evaluate neglect; should it be from the parental perspective with the definition solely being an omission of care or from the child’s perspective of lacking basic needs? Researchers have attempted to look at it from both perspectives (Mulder et al. 2018). Knowing the true prevalence of child physical neglect, as with most types of maltreatment, is difficult. This is due to only knowing about reported cases to either child protective services or law enforcement (Schilling and Christian 2014). In a meta-analysis conducted by Stoltenborgh et al., the overall prevalence of physical neglect was 163/1000, or 16.3%, with no statistical significance between males and females (Stoltenborgh et al. 2013). Other studies have shown an increased risk of physical neglect with younger children being at highest risk from improper care, but with older children having a higher rate of physical neglect due to lack of hygiene (Vanderminden et al. 2019). However, as the authors note, data are limited due to inconsistencies of how information is collected across studies. Physical neglect is seen across the globe and throughout all socioeconomic classes (Vanderminden et al. 2019). Lower socioeconomic status is a risk factor for physical neglect. However, supervisory neglect is more prevalent in high socioeconomic status (Turner et al. 2019; Vanderminden et al. 2019). Research has established links between IPV and physical neglect as well (Afifi et al. 2017). Professionals in the field of child maltreatment should be aware of the risk of harm to children from physical abuse or physical neglect if intimate partner violence is present in the home. Case Example

A sibling set of 8-year-old twins are brought by emergency medical services to a local emergency room after one sibling escapes the home. The twins disclose (continued)

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that their caregivers keep them locked in a bedroom. The door has two locks and is barricaded on the outside. They have no access to a bathroom, and they do not receive food daily. They are disheveled in appearance with stool caked on their feet and hair. Their ankles reveal circular excoriations which the children report is secondary to restraints with handcuffs. Scene investigation reveals a room with no furniture or toys. The floor is covered in stool. Handcuffs are present and attached to a railing in the closet. There is no running water in the home. The children are placed in state custody, and parents are arrested at the scene.

Special Considerations When considering physical neglect, there are certain populations of children who are at a higher risk of neglect. One subset of children at high risk for physical neglect includes migrant and immigrant children (Wen et al. 2019). The effects of physical neglect place these children at higher risk for poor outcomes such as behavioral problems and long-term adverse mental health diagnoses (Wen et al. 2019). These children are labeled “left behind children,” as their primary caregivers will leave them with other family members or even non-related individuals for extended periods of time or even indefinitely (Wen et al. 2019). Data indicates these children have a higher risk for behavioral problems related to inattention which can affect overall development and education (Wen et al. 2019). Another group at high risk of physical neglect are adolescents. One study demonstrated physical neglect is a strong predictor of physical violence in adolescent males. It also showed the effects of physical neglect on the risk for violent behavior by adolescent males were similar to those who had only experienced physical abuse (McGuigan et al. 2018). While all children who are physically neglected have an increased rate of sexual abuse, adolescent females have a slightly higher prevalence of sexual abuse compared to adolescent males (Turner et al. 2019).

Diagnostic Evaluation As with all suspected child maltreatment, concerns for physical neglect are best addressed with a full multidisciplinary team approach. Investigators with child protective services and law enforcement should conduct a thorough scene investigation of the environment in which a child or children are found. Photographs of the scene should be taken and include aspects such as cleanliness (or lack thereof); plumbing; electricity; available food; access to safe sleeping environments (especially with infants); and any other unsafe conditions such as weapons in the home or drug paraphernalia. Investigators should also document animals in the home to include signs of animal neglect or cruelty (Bright et al. 2018; Newland et al. 2019). Evidence

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of restraint or confinement including locks, cages, kennels, ropes, handcuffs, or ties should be documented and collected. Details of the environment that are concerning for past or current IPV should be documented including, but not limited to, holes in walls and broken furniture.

Treatment All children who are suspected victims of neglect should have a medical evaluation as soon as possible. This evaluation should be conducted in a child-friendly environment by a provider with training in the field of maltreatment. A full history should be obtained by any caregiver who understands collection of medical history. Additional historians may include, where applicable, child protective service workers, law enforcement, and forensic interviewers. History should also be elicited from the child by the medical provider in a manner that is age appropriate and with an attempt to limit the impact of the trauma of asking a child to share details of their neglect. The physical exam should be a complete head to toe exam with attention paid to the child’s overall well-being. Any and all injuries should be documented with digital photography noting any concerns for physical abuse. The skin exam should also include documentation of signs of nutritional deficiency. The child’s growth parameters should be plotted on an appropriate growth chart, with efforts made to find previous measurements to gauge overall growth. The child’s development should be assessed through observation with additional testing as indicated. The evaluation should conclude with discussing the exam with the child, as age appropriate, and any protective caregiver present. Diagnoses and opinions should be relayed to the appropriate authorities with child protective services and law enforcement. Some children may need to be hospitalized for additional workup. Indications for hospitalization include moderate to severe malnutrition, co-occurring physical abuse injuries such as head or abdominal trauma, and exacerbation of an underlying untreated medical condition such as asthma. Additional workup might include basic laboratory studies such as a complete blood count, complete metabolic panel, urinary analysis, urine or blood drug screens, and testing for malnutrition (complete blood count, comprehensive metabolic panel, urinary analysis, pre-albumin, and thyroidstimulating hormone) as indicated; radiological studies such as skeletal surveys or head computed tomography can be ordered (Delgado Alvarez et al. 2016).

Nutritional Neglect Introduction Nutritional neglect is the form of neglect in which the nutritional needs of a child are not met. It is considered a subset of physical neglect. Nutritional neglect is the omission to provide adequate and/or appropriate nutrition, and it involves a wide

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spectrum of deficiencies including poor dietary choices, obesity, failure to thrive, and severe malnutrition leading to death. Abnormal growth out of the expected range can be an early indicator that something is wrong with the health or home environment of a child. Most children grow and develop according to an expected trajectory with a normal weight range for each age. Deviation from this trajectory is an indication that further evaluation is needed. Children who are truly failing to thrive will not have the expected progress in growth and development. Both failure to thrive and childhood obesity have immediate and long-term impacts on the health of a child and may also have effects on lifelong health, depending on the severity. Adequate nutrition is needed for appropriate child growth and development. Infants especially require large calorie intake per kilogram of weight to support their rapid growth. An infant’s growth gradually slows down during the first year and stays at a steady rate until puberty, at which time it speeds up again. Children grow at a rate of 25 cm/10 inches per year from birth to age 1 year. Growth slows down after this to an average of 12 cm/5 inches per year from age 1 to 2 years and 8 cm/3 inches from age 2 to 3 years. The rule of five then suggests that growth further slows to 5 cm/2 inches per year from age 4 to 8 years (Olsen 2006). A healthy diet includes protein, carbohydrates, fats, vitamins, minerals, and water. There are many reasons that a child may not receive adequate nutrition, including lack of resources, lack of education, or lack of motivation. Other etiologies for inadequate nutrition include food insecurity, poverty, living in a food desert, mental illness in a parent, maternal depression, parental drug abuse, and domestic violence. Monitoring growth is part of routine medical care. When children are seen by a medical care provider, they are weighed and measured, and these values are plotted on growth charts. Measurements obtained include height for age, weight for age, and, in children under 2 years old, head circumference. Infants should be weighed and measured naked or in only a dry diaper. Older children should be weighed in light clothes and without shoes. Over time, the weights plotted on a growth chart will show if a child is growing appropriately. Both the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) have sets of growth charts. The two sets of charts are different in that the WHO charts are growth standards and reflect how healthy children should grow under optimal environmental and health conditions. The CDC charts describe the growth of children in the United states during a specific time span (GrummerStrawn et al. 2009). The WHO charts should be used for children from birth to age 24 months, and from age 2 years to 18 years, the CDC growth charts should be used (Olsen et al. 2010). Certain populations of children do not follow the growth trajectories on these charts. There are specific growth charts available for prematurity, cerebral palsy, trisomy 21, Turner syndrome, and Williams syndrome, among other conditions (The CDC Growth Charts for Children with Special Health Care Needs 2014). The pattern of deviation on a growth chart can give a clue as to an underlying cause. In children who aren’t getting enough calories for growth, the weight falls

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off the growth curve before the height and head circumference. If a child’s stature falls off before weight, it can indicate an underlying medical problem such as hypothyroidism. Ideally a growth chart will have several points, so growth over time can be evaluated; however, if only one point on a growth chart is available, percentiles and z-scores can be used to determine growth deviation or malnutrition (Becker et al. 2014).

Failure to Thrive Failure to thrive refers to a child who, through comparison of his or her anthropometric measurements, is not growing and developing appropriately as compared with recognized growth patterns adjusted for age and gender (Block and Krebs 2005). It is also referred to as growth faltering or growth failure; however, in this chapter, failure to thrive will be used. Failure to thrive refers to a state of undernutrition resulting in growth deviation regardless of the underlying cause (Olsen 2006). The term failure to thrive refers to a symptom and doesn’t point to a cause. There is no consensus about which specific anthropometric criteria is best for identifying children who are truly failing to thrive (Olsen 2006). Previously failure to thrive was divided into two large categories, organic and non-organic, organic meaning that the failure to thrive is due to an underlying medical condition and non-organic referring to not being provided enough calories for social or environmental reasons. For most children, failure to thrive is not clear-cut. It is the result of an imbalance between nutrient requirement and intake or delivery. Malnutrition occurs along a continuum of inadequate intake and/or increased requirements, impaired absorption, and altered nutrient utilization. Failure to thrive can occur at many points along this continuum (Mehta et al. 2013). Children with failure to thrive often have components of both an underlying medical condition and biopsychosocial reasons for not receiving enough calories. Children with underlying medical conditions are often difficult to feed and can have increased calorie requirements, putting them at higher risk of failure to thrive. Anthropometric indicators used to evaluate whether children are failing to thrive are usually based on percentile charts for weight and height (Olsen et al. 2007). Frequently used chart-based definitions of failure to thrive include a child whose weight is below the third or fifth percentile for age on more than one consecutive occasion, a child whose weight drops down two major percentile lines, a child whose weight is less than 80% of the ideal weight for age, or a child who is below the third or fifth percentile on the weight-for-length curve (Jaffe 2011). Commonly used definitions used for failure to thrive include weight of 75% of median weight for chronological age (Gomez criterion), weight of 80% of the median weight for length (Waterlow criterion), body mass index for chronological age at the fifth percentile, weight for chronological age at the fifth percentile, a weight deceleration crossing more than two major centile lines, and conditional weight gain equaling the lowest 5% adjusted for regression toward the mean from birth until weight within the given age group (Olsen et al. 2007).

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Diagnostic Evaluation All children being evaluated for failure to thrive should undergo thorough history and physical examination. The history should include eating habits of the child, past medical history, family history, and social history (Fig. 2). Having a family keep a food diary can be helpful in evaluating food quantity and quality. Providers should assess whether the child is meeting his developmental milestones and ask about the child’s temperament. A complete review of systems should be obtaind including, but not limited to, sypmtoms of infection, respiratory illness, gastrointestinal illness and urnary output. A full, unclothed physical exam can give clues as to the etiology of failure to thrive. Full measurements should be taken of the child, not only height and weight but mid-upper arm circumference (MUAC) (Becker et al. 2014). The clinician should carefully evaluate for a heart murmur, dehydration, edema, protuberant abdomen, wheezing, congestion, increased work of breathing, birth marks, dysmorphisms, and body habitus. Although not common in developed countries, a clinician should be cognizant of kwashiorkor and marasmus. Providers should plot the child’s growth on a growth chart as described above and then evaluate the shape of the curve and the overall percentages. Electronic medical records (EMRs) can calculate the growth percentiles and plot the growth; however, EMRs are sometimes inaccurate, and there may be benefit to manually plotting on paper. The MUAC can be used as an independent anthropometric assessment in determining malnutrition in children ages 6–59 months as compared to WHO standards (Becker et al. 2014). Z-scores can be used to determine the severity of the failure to thrive, especially at the extreme ends of the ranges. A z-score is a standard deviation (SD) score that can help determine the severity of the malnutrition of a child based on the WHO Global Database. A child at the 50th percentile on a standard growth chart is considered a 0 for a z-score. Heights and weights are distributed along a bell-shaped curve, and the whole population is under the curve. If the child is above the average weight for age, the z-score is a positive value (1, 2, 3); if the child weighs less than the average weight for age, the z-score is a negative value ( 1, 2, 3). The calculated score can be compared to data files to determine the severity of the malnutrition; one standard deviation from the mean plots at the 15th or 85th percentile, and two deviations plot at the third or 97th percentile depending on whether the z-score is positive or negative. A child with less than 2 SD from the mean is mildly malnourished and 3 or less is severely malnourished (De Onis et al. 1997). The lab and radiology workup should be guided by the history and physical examination. In most cases, only a basic lab workup is warranted, but the physical exam may indicate the need for more testing. The basic lab workup includes complete blood count, chemistry, thyroid-stimulating hormone, and urinalysis with culture. Based on these results combined with the physical exam, determination of further lab work needed can be made, such as including calcium, magnesium, and phosphorus for refeeding syndrome, sweat testing for cystic fibrosis, or serologic markers for inflammatory bowel disease (Pulcini et al. 2016). Children with heart

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Toddler & Older Child Feeding History Prenatal History Medical History

Family History

Fig. 2 Failure to thrive medical history

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•Frequency of feeds •Duration of feeds •Latching difficulty •Dribbling with feeds •Frustrated with feeding •Temperament of child •Sweating with feeds •Breast Fed •Breastfed latching problems •Mom's breasts feel full •Feel milk letdown •Infant sucking and swallowing sounds •Formula Fed •Formula type •Preparation •Quantity eaten •Who provides the bottle •Temperament of child •Picky eater •Problems with textures •Distractions at mealtime •Types of foods preferred/eaten •Eat as meals vs grazing all day •Consistently eat in the same place •Who prepares food, feeds child •Planned pregnancy •Maternal illnesses during pregnancy •Maternal illicit drug or alcohol use •Maternal smoking or vaping •Complications with pregnancy/delivery •Gestational age •Chronic medical problems •Frequent infections •Frequent hospitalization •History of seizures •Antibiotic used •Surgical history •Parental height •Growth problems •Short stature •Developmental delay •Genetic/metabolic syndromes •Seizure history •Cardiac problems •Pulmonary problems •Inflammatory bowel diseases

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murmurs or sweating with feeds should have an echocardiogram. Infants and toddlers with concerning injuries will need a skeletal survey. Older children may need radiology studies for bone age determination or to rule out skeletal dysplasias.

Outcomes Failure to thrive has potential risk for long-term growth and development (Jenny 2011). Early identification and treatment of failure to thrive can help improve outcomes. Immediate consequences include loss of subcutaneous fat, vitamin and mineral deficiency, delay in feeding skills, and delayed social skills. Children who present with long-term failure to thrive are at risk of refeeding syndrome (Pulcini et al. 2016). The first years of life are ones of not only rapid physical growth and development but also of rapid brain development, and malnutrition during this time can affect development; these children can miss important developmental milestones that make up the foundation of later learning (Jenny 2011). Some children develop oromotor dysfunction, disordered eating, and disordered social responses. For example, a young infant whose caretaker is not responding to his or her cues of hunger may not learn to respond back to a caretaker appropriately. This child may also stop crying for food because of the lack of response leading the caretaker to ignore the feeding needs of the child. The long-term consequences follow these children through the school years into adulthood. By age 8 children who had appropriate growth as infants and toddlers were overall taller than their FTT counterparts that didn’t have early intervention as well as those that did (Black et al. 2007). Children in poverty with a history of FTT had significantly lower cognitive development than those with no history of FTT during infancy and preschool years, although the differences were no longer significant once in school (Mackner et al. 2003). For the school-aged child, being hungry can lead to difficulty concentrating at school and thus difficulty learning. Poor growth at age 2 has been shown to cause lower test performance in school. As adults, the children with failure to thrive at age 2 have a lower household per capita expenditure and an increased probability of living in poverty. For women it is also associated with a lower age at first birth and higher number of pregnancies and children (Hoddinott et al. 2013). Risk Factors and Causes Causes of failure to thrive can be divided into large categories including the need for increased calories (increased energy consumption; not absorbing enough calories/ high output; and not being provided with adequate calories/low input). Children with chronic medical diseases will require more calories due to the excess energy required by the condition, particularly children with heart and lung disease (Fig. 3). The greatest risk factor for failure to thrive is poverty (Block and Krebs 2005). Parent Child Interaction Watching a parent feed the child can give important information as to the cause of the failure to thrive. This can be done in a clinic or hospital setting. One study demonstrated differences between mothers of children with growth failure and mothers of controls, with nearly twice as many positive interactions in meals eaten

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Increased Caloric Need • Congenital heart disease • Lung disease, BPD, CF • Renal disease • Inborn errors of metabolism

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Increased Output

Decreased Input

• Inflammatory bowel disease • Celiac disease • Other malabsorption • Chronic diarrhea

• Parental depression • Parental drug use • Inappropriate feeding expectation • Lack of parent understanding of child development

Fig. 3 Causes of failure to thrive

by controls, compared to children who are failing to thrive (Robertson et al. 2011). Watching the infant feed can determine whether there are problems with the way a child ingests food (e.g., oromotor dysfunction, food aversion) and if the parent is feeding appropriately. Maladaptive feeding patterns and responses may become apparent, and infant attachment (as well as disturbances in attachment) can be evaluated. Considerations include if the infant cries when hungry and if the parent responds to the infant cries. What is the response of the caregiver to the child’s refusal of food? Is the parent getting up at night to feed a hungry infant? Does the toddler throw a tantrum when food he does not like is presented? Some children may need feeding therapy with a speech therapist. Parents may need family support systems and/or therapy.

Treatment The physical examination, growth charts, hydration status, and z-scores can be used to determine if a child needs to be hospitalized or can be treated as an outpatient. All feeds, regardless of whether inpatient or outpatient, should be tracked carefully. A child’s caloric needs should be calculated and should include calories for catch-up growth. Children may need a speech therapy evaluation to evaluate for feeding problems; this can be done as an inpatient or outpatient. If a child is severely malnourished, dehydrated, or at risk for refeeding syndrome, he or she should be hospitalized. Risk factors for refeeding syndrome in young children include fasting greater than 5 days, children with complex health needs, oncologic patients, neglected and abused children, homeless children, short bowel syndrome, significant vomiting and diarrhea, and acute weight loss greater than 10%. In older children depression and chronic alcohol and drug use can play a part. Refeeding syndrome occurs when, upon introduction of food, a malnourished system has to readjust from a stress system using the body’s fats for energy

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to digestion of carbohydrate-containing foods. This can cause potentially fatal electrolyte and fluid shifts. Hypophosphatemia is the main concern with refeeding; however, a child with feeding syndrome may have abnormal sodium and fluid balances; changes in glucose, protein, and fat metabolism; thiamine deficiency; hypokalemia; and hypomagnesemia (Mehanna et al. 2008). Slow reintroduction of food helps prevent refeeding syndrome, and labs should be monitored frequently. These children may need nasogastric feeds and speech therapy if oromotor dysfunction or food refusal is present. Infants whose caregiver might not bring the child back for follow-ups may benefit from hospitalization. In a hospitalized child, parent-child feeding interactions should be monitored and tracked carefully. If a parent is refusing to feed a child in the hospital, such information should be noted and reported to any involved investigative agency. For outpatient treatment, medical providers must instruct the family on how to keep a food diary. A food diary should include the date/time of the feed, the type of food, duration and volume of the feed, and any barriers to feeding including spitting up and/or choking. For toddlers it is more difficult to compose a diary, as families may not give the child measured amounts of food. As much as possible, caregivers should include details regarding what the child ate and drank; the time of the meal; and their location during the meal (e.g., infant seat, toddler table). Infants will need to come back frequently for weight checks, sometimes as often as every day, and toddlers may need to come back weekly. Pharmacotherapy is not generally recommended, but for children with underlying chronic medical conditions like cystic fibrosis, cyproheptadine can help stimulate appetite. Children with oromotor dysfunction and food refusal may need a feeding tube while continuing with speech therapy and other therapies to help them readjust to a normal diet. Education should be provided on how to feed a child during the evaluation. Social services will need to be involved if the family is not bringing the child back for follow-up or refusing care. Child protective services can visit the home to make sure that there is food available to the child and assist families to procure resources such as Women, Infants, and Children (WIC), which provides food for low-income families. When a child has shown appropriate weight gain and the child is in an environment where he or she will continue to receive appropriate and adequate nutrition, that child can be released from FTT follow-up. Case Example

A 7-month-old female is brought to an urgent care for a new-onset rash. During the skin exam, the medical provider notices that the child appears emaciated. She is wearing 0–3-month clothing. Her arms and legs are thin, her ribs are prominent, and she has thin hair and temporal wasting. She is half a pound above her birth weight. Mom stated she is formula fed by her boyfriend during the day while Mom works, and the child sleeps all night. She has not been ill recently. The child was admitted to a local hospital for failure to thrive and medical neglect.

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Severe Malnutrition and Fatal Nutritional Neglect Severe malnutrition, whether fatal or nonfatal, is an uncommon, severe form of failure to thrive (Kellogg and Lukefahr 2005). Change in body habitus with wasting is obvious. With severe malnutrition, victims will show multi-organ effects of prolonged malnourishment and deprivation, such as kwashiorkor, increase in opportunistic infections, or decreased healing of lesions, and those who survive can have significant cognitive delays and physical consequences (Kellogg and Lukefahr 2005). These children should have skeletal surveys to screen for skeletal injury as well as growth arrest lines which can be seen on X-ray and are a sign of prior stress with a resultant arrest of bone formation. Tenting of the skin and sunken fontanelles and eyes also indicate dehydration (Gill 2013). A full autopsy should be performed in cases of suspected fatal starvation.

Obesity Obesity, like failure to thrive, is a symptom which does not indicate an underlying cause. It is caused by an imbalance of energy consumption versus energy expenditure leading to an accumulation of excess fat. Obesity as a form of neglect might apply when the family of an obese child fails to provide medical care or control their child’s behavior placing the child at risk of serious harm and even death (Varness et al. 2009). Obesity as a form of child neglect is most often seen in affluent countries. Obesity has been on the rise in the United States, and it affects about 13.7 million children and adolescents. The prevalence is 13.9% among 2- to 5-yearolds, 18.4% among 6- to 11-year-olds, and 20.6% among 12- to 19-year-olds. Childhood obesity is also more common among certain populations. Hispanics (25.8%) and non-Hispanic blacks (22.0%) have higher obesity prevalence than non-Hispanic whites (14.1%). Non-Hispanic Asians (11.0%) have lower obesity prevalence than non-Hispanic blacks and Hispanics (Hales et al. 2017). Overweight refers to a child with a body mass index (BMI) between the 85th and 95th percentiles for age and gender, whereas obese refers to a BMI of >95th percentile, and severely obese refers to children with BMI of >99th percentile. The term “obesity with comorbid conditions” refers to children with diseases that are secondary to obesity (Varness et al. 2009). Many factors contribute to the increase of obesity including genetics, metabolism, eating behaviors, level of physical activity, stressors in the home and school, adverse events, neighborhood safety, and distance to available healthy foods. A genetic component for obesity is shown in prevalence differences between racial groups, and familial occurrences of obesity have been noted with concordance for fat mass among monozygotic twins being much higher than dizygotic twins (Zhao and Grant 2011). Fast food and junk food are cheap and easily obtainable; also, children like it. Food deserts in low-income areas make access to healthy food difficult. The cost of healthier foods may pose an insurmountable obstacle for families who are struggling with food insecurity, such that they frequently buy cheap, filling food to

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ensure that their food supplies last. Medical professionals may perceive a parent’s insistence on buying cheap foods as noncompliance with medical recommendations, which may in itself prompt a referral to child protective services. A parent may not pay attention to what a child eats or, when he eats, leave a child to obtain food for himself. A parent may not know what constitutes a healthy diet for a child and what appropriate portions are. Most obesity is caused by a combination of these factors of food access, genetics, and failure to follow medical advice; it is a complex multifactorial disease with an interaction between these behavioral, environmental, and genetic factors (Zhao and Grant 2011). Obesity has both short- and long-term consequences on child health through comorbidities and psychological impacts. Short-term impacts include decreased ability to engage in everyday activities as well as the social stigma of being obese. Obesity can affect a child’s self-esteem, and obese children may be bullied for their appearance. Childhood obesity can cause hypertension, cardiorespiratory disease, type two diabetes, sleep apnea, and fatty liver disease. In severe cases a child may need positive pressure ventilation while sleeping. A child’s ability to walk even a short distance can be impacted. Although not all obese children become obese adults, there is an association between overweight and obesity with the same in adulthood, especially in children with higher BMIs or if they have an obese parent (Biro and Wien 2010). Similar adverse health effects (hypertension, heart disease, diabetes) are seen in adults. There are adverse social effects of obesity in adulthood, just as in childhood. During puberty there is a rise in insulin resistance and worsening of components of metabolic syndrome such as elevated triglycerides, low HDL, abdominal circumference >90th percentile, elevated fasting glucose, and high blood pressure. Childhood obesity is associated with earlier pubertal maturation in girls (Biro and Wien 2010).

Evaluation Obese children need a full history and physical exam, including a thorough medical and social history. Blood pressure should be monitored. The physical exam should include evaluation for signs of underlying medical conditions. Lab workup should include CBC, complete chemistry, TSH, fasting lipids, and HgbA1C. Treatment Obesity can be difficult to manage because it is a complex multifactorial disease. The component cannot be changed and familial habits are hard to change. Parents may not seek help for their children because of guilt or feeling blamed for the child’s weight. Poverty is a risk factor for obesity. Parents may not be able to afford or have access to healthy foods for their children; they also may not have access to a safe neighborhood where children can play outside. Some parents may not be willing to change their eating habits. A multidisciplinary treatment approach is more successful in treating obesity. Families of these children will need medical care to monitor weight and comorbidities, nutritional counseling and monitoring, access to exercise, and resources for food, along with individual and family counseling. The goal of treatment is to improve the obesity and help the child and family develop lifelong

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healthy habits without the social stigma associated with some weight control programs. Clinics have been developed in some areas to address the multifactorial aspects of obesity and include medical care, nutrition advice, counseling, exercise advice, and physical therapy in one location. The question often arises of when obesity constitutes child neglect and whether this warrants removal of a child from home. Removal of a child from the home in itself can have negative consequences. It is difficult to determine the imminent harm of obese children. The removal of a child from the home can be justified if three conditions are present: (1) a high likelihood that serious imminent harm will occur; (2) a reasonable likelihood that coercive state intervention will result in effective treatment; and (3) the absence of alternative options for addressing the problem. It is not the mere presence or degree of obesity, but rather the presence of comorbid conditions, which is critical for the determination of serious imminent harm (Varness et al. 2009).

Educational Neglect Introduction Educational neglect is an understudied aspect of child maltreatment. It is defined as a parent or caregiver actively or passively not attending to the educational or developmental needs of his or her child, which compromises the child’s development or well-being (Van Wert et al. 2017). Educational neglect has a different presentation depending on the developmental stage of the child. With a young child, it may include not working with the child to identify letters, numbers, shapes, and colors. With an older child, it may include not enrolling the child in school or engaging in homeschooling. It also includes allowing the child to be absent from school without a valid excuse such as an illness or family emergency. In the context of special education, caregivers and school systems must address a child’s individual educational needs with tools such as an individualized education plan or 504 plan, thereby allowing the child to meet his or her educational goals. With an adolescent, educational neglect can occur when the parent or caregiver is complicit with truancy.

Diagnostic Evaluation While research in the field of educational neglect is not as robust as other forms of child maltreatment, there are certain trends that are well documented. Adolescents who attain higher levels of academic achievement are more likely to have improved health behaviors such as regular exercise and healthy diets and reduced risky health behaviors and less likely to be incarcerated, unemployed, and have behavioral problems or shortened lifespans (Dube and McGiboney 2018). Truancy and educational neglect are strongly linked (Van Wert et al. 2017). While school attendance

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tends to be the purview of child protective services and school systems, it is appropriate for the medical provider to inquire about a child’s education and development. A routine health maintenance exam should include an inquiry into the child’s school placement, grade, academic success, necessity for academic modifications such as individualized educational plans, and rough percentage of attendance. The medical exam is an opportunity for intervention to identify barriers to education. Any noncompliance with enrollment in school or attendance should be reported to child protective services in an attempt to improve the academic outcome for the child. Case Example

A healthy 7-year-old boy presents for his routine health maintenance exam. The physician inquires about how the school year is going. The child reports he has never been in school. The parents deny homeschooling. The child is unable to identify any numbers or letters. The physician instructs the parent to take the child to the local educational service center to enroll the child. A report to child protective services is indicated.

Emotional Neglect Introduction Emotional neglect, like other forms of neglect, is an act of omission. Rather than caring for and nurturing a child, the parent or caregiver does not attend to the child’s emotional well-being. Emotional neglect also includes exposure to domestic violence and/or substance abuse. In 2017, emotional maltreatment accounted for 2.3% of single act maltreatment cases (Child Maltreatment 2017). NCANDS does not specifically delineate emotional neglect or emotional abuse, and so a percentage of these cases are abusive rather than neglectful in nature. Emotional or psychological abuse differs from emotional neglect in that the caregiver verbally abuses, intimidates, or coerces the child. Emotional neglect is a failure of an adult to respond to a child’s emotional needs. This type of neglect can result in emotional, behavioral, educational, socialization, and attachment problems with children (Dubowitz and Black 2009). Most maltreatment in infancy is neglect, and as infancy is the time of period of greatest health surveillance in a child’s life, it is important for medical providers to be aware of the outcomes of emotional neglect. Children who are victims of emotional neglect can have poor attachment to their caregivers. They can exhibit atypical behaviors such as apathy in a toddler to abnormal behaviors such as repetitive movements (Dubowitz and Black 2009). There are a variety of longterm consequences for psychological maltreatment, including negative emotional worldviews, low self-esteem, increased mental health problems, poor emotional

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health, diminished social skills, impaired learning, and poor physical health (including failure to thrive and high mortality) (Kairys and Johnson 2002). Case Example

A 3-year-old female is found wandering in a hotel parking lot. She exhibits limited vocabulary, repetitive hand movements, and inappropriate attachment with strangers. Child protective services and law enforcement attend to the child as a joint response. CPS identifies her parents, and law enforcement reports that they responded to the hotel the preceding night for a domestic violence incident and parents were found in possession of methamphetamine. The child is placed in a foster home and engaged in therapy. With an intensive therapy and secure attachment with her foster family, the child begins to make developmental gains.

Diagnostic Evaluation Emotional neglect and its larger subset of emotional maltreatment can be difficult to diagnose, because diagnosis is based on the parent-child dyad as opposed to the event(s) that occur with the relationship. As this type of maltreatment is difficult to diagnose, treatment may be delayed, which can yield negative outcomes (Hibbard et al. 2012). When emotional neglect is suspected, a medical evaluation is indicated to examine for other forms of abuse and neglect, to assess the child’s developmental and behavioral metrics, to ensure that appropriate therapeutic interventions are in place, and so that referral to law enforcement and child protective services occurs, if indicated. Medical providers should be cognizant of risk factors associated with psychological maltreatment including parental mental health disorder, substance abuse, and intimate partner violence. However the presence of substance abuse and intimate partner violence is in themselves forms of emotional neglect. Literature is scarce for effective treatment of psychological maltreatment; however child maltreatment prevention programs such as nurse home visitation programs can play a role in mitigation of psychological maltreatment (Hibbard et al. 2012).

Medical Neglect Introduction Medical neglect is the failure of a caregiver to provide adequate medical care for their child either by noncompliance with recommendations by health-care providers or by failure to obtain medical care that results. Either of these acts results in “probable or significant harm” to the child (Dubowitz et al. 2000). In 2017, medical

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neglect accounted for 2.2% of all forms of child maltreatment (Child Maltreatment 2017). The actual numbers are likely much higher as the more severe cases of medical neglect are more likely to be reported, whereas less severe cases may never be reported. Considerations for a provider to diagnose medical neglect include the potential for harm without treatment, the benefit to receiving treatment, the caregiver’s understanding of the treatment, and access to the treatment (Jenny 2007, 2011). There are some medical recommendations that parents who are noncompliant with that do not rise to the level of medical neglect. Case Example

A 4-year-old male has had recent weight loss, polyuria, and polydipsia and acutely has developed labored breathing and altered mental status. The family recognizes he is ill but does not seek care. The family is unable to wake the child one morning and subsequently contacts emergency medical services. The child is diagnosed with DKA and started on an insulin drip. Prior to discharge, the family is educated on proper administration of insulin and advised to follow up with pediatric endocrinology. The family does not attend the follow-up appointment and never fills his prescriptions for insulin. The child is found dead 2 weeks later. Forensic interviews of the older children indicate that the child developed labored breathing and altered mental status for the days preceding his death and that his parents never provided him any medication. His parents were criminally charged with neglect.

The medical provider should be well versed in the barriers to obtaining medical care. The barriers can be divided into patient or family related and physician related (Fig. 4). As with other forms of neglect, poverty can be a driving force for medical neglect. Families may not have the financial resources to provide health insurance or health care, transportation to a clinic, or the ability to take time off of work to seek medical care. Caregivers also may have diminished intellectual capacity, or may be under the influence of substances, and are therefore unable to recognize the need for medical care. Similarly, mental illness in the caregiver can function as a barrier to care. Discord in the household or distrust of the medical provider can also inhibit access to medical services. Likewise, the patient’s or family’s religious beliefs may not be in line with the provider’s recommendations. Finally, it is not uncommon for adolescents to push boundaries and rebel against medical treatment, especially those with chronic medical conditions (Dubowitz et al. 2000; Jenny 2007). Compliance becomes problematic with adolescents as they are becoming more independent and taking ownership of their medical problems. Conversely, it is important that the medical provider make every effort to ensure that patients and families be informed so that the best medical decision-making is in effect. Communication and recognition of a caregiver’s health literacy are key. It is also important for physicians to be culturally competent (Dubowitz et al. 2000; Jenny 2007).

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Fig. 4 Barriers to medical care

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Individual Barriers

Physician Barriers

Financial • Lack of Health Insurance • Lack of Transportation • Inability to Miss Work to Seek Care

Cultural Competency

Belief Systems

Communication

• Religious Tenets • Concerns About Vaccine Safety and Necessity

• Language Barriers • Caregiver Health Literacy

Cognitive • Intellectual Disabilities • Substance Abuse • Mental Health

Compliance • Adolescent Ownership of Medical Decision Making • Distrust of Medical Providers

Diagnostic Evaluation When addressing medical neglect, the medical provider should engage the family to identify the barriers to receiving care, address the caregivers’ concerns regarding treatment options, and collaborate with the family to create a treatment plan (Jenny 2007). Medical providers and families can enter into a care contract outlining the responsibilities of the caregiver and child, if applicable, as it pertains to the treatment of the child’s disease state (Laskey and Sirotnak 2019). Home health services can provide additional support to the family and reduce the burden on the primary caretaker. Medical social workers can function as part of a team approach and offer community resources to the caregiver(s). A referral to child protective services is indicated when the lack of medical care puts the child at risk of harm. Involvement with CPS has the potential to provide further resources to the family and child including parenting capacity, substance abuse, and mental health assessments. Out of home placement is reserved for the most severe cases of medical neglect or where caregivers cannot or will not comply with a treatment plan (Laskey and Sirotnak 2019).

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Dental Neglect Dental neglect is a subset of medical neglect. The American Academy of Pediatric Dentistry defines dental neglect as “willful failure of parent or guardian, despite adequate access to care, to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection” (Definition of Dental Neglect 2016). Inadequate attention to the dental health can lead to dental caries and other oral hygiene diseases which can ultimately yield the potential for infection and other morbidity (Fisher-Owens et al. 2017). Typically, to diagnose dental neglect, a caregiver should have been previously advised to seek dental care for the child and should have limited barriers to seeking care. The diagnostic considerations are similar for dental neglect as compared to medical neglect, including the risk of harm, that the treatment offers significant benefit over the associated morbidity; there is access to dental care, but it is not used; and caregivers understand the recommendations for care. A health-care provider should consider a diagnosis of dental neglect after a caregiver has been thoroughly appraised of dental condition associated with increased morbidity, that the condition has a treatment plan where the benefits outweigh the risks, the child has reasonable access to care, and efforts have been made to overcome any potential barriers to care such as financial constraints and transportation, yet the caregiver opts to not seek dental care (Fisher-Owens et al. 2017).

Autonomy Parental autonomy is a doctrine that parents are able to raise their child according to their beliefs. However, parental autonomy may not be honored when the child is in a position of harm. Parens patriae, which means “parent of the nation,” is a legal construct which can be invoked after a parent places a child in a position harm. The care of the child is then transferred to the state for his or her protection (Dubowitz and Black 2009). This doctrine is used when a parent refuses treatment based on religious or other beliefs and withholding the prescribed treatment is lifethreatening. The American Academy of Pediatrics strongly objects to religious exemptions (American Academy of Pediatrics Committee on Bioethics 2013). A classic example of parens patriae is a young child in need of a lifesaving blood transfusion, but parents are refusing a transfusion secondary to their beliefs as Jehovah’s Witnesses. As a blood transfusion is medically necessary, courts have upheld placing a child in the state’s custody to receive the lifesaving treatment.

Supervisory Neglect Failure to supervise involves leaving a child unsupervised, not providing a safe environment, not providing adequate caregivers, or engaging in harmful behavior. Failure to supervise can be dependent on the age of the child and the length of time the child is alone. The American Academy of Pediatrics defines supervisory neglect

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as “whenever a caregiver’s supervisory decisions or behaviors place a child in his or her care at significant ongoing risk for physical, emotional, or psychological harm” (Hymel 2006). State statutes vary in their determination of what is an appropriate age to leave a child alone, how long to leave a child alone, and how old a caregiver must be to provide care for other children. The child’s developmental capabilities are also mitigating for failure to supervise. Some children are developmentally ready to be left alone at a younger age, whereas other children require further supervision. Similarly, some children are able to provide care for younger siblings at a younger age than others. As such, there is no definitive diagnostic criteria for failure to supervise; however, clinicians should be cognizant of the local statutes regarding child supervision. The clinician should also be aware of different cultural mores regarding supervision. In some cultures, older siblings are expected to care for their younger siblings at ages that generally would not be acceptable in the United States. Abandonment is a form of inadequate supervision defined by not claiming a child within 2 days or forcing a teenager to leave the home (Dubowitz and Black 2009). On the contrary, “helicopter parenting,” a form of parenting where the parent is developmentally overly engaged in the child’s life, is associated with increased anxiety and depression in children which is generally related to hampering the child’s perceived autonomy and competence (Schiffrin et al. 2014). Case Example

A 7-year-old girl is kept out of school and left in charge of her younger siblings who are 9 months old and 2 years old during the day. Her parents cannot afford to take time off from work and have no other available babysitter. The girl attempts to make grilled cheese for lunch but burns the sandwich and smoke detectors sound. A neighbor contacts 911, and the local fire department arrives on scene to a home filled with smoke and the three young children hiding in a bathroom. The 7-year-old has a forensic interview and notes that she frequently is responsible for feeding her siblings. She gives both bottles of milk present in the refrigerator and puts cereal on the ground for the children to eat. She attempts to change diapers but described both children as “wiggly” and stated she does not change them frequently. CPS workers describe the 7-year-old as “parentified.”

Another aspect of failure to supervise involves not taking reasonable steps to protect children from unintended harm. A toddler left playing near a pool without a caregiver nearby who subsequently drowns is a neglectful act. However, a toddler who falls while learning to walk and suffers a toddler’s fracture is not neglectful. Determination of when to contact child protective services should be based on local statutes; the timing and circumstances of the lack of supervision; the child’s developmental, physical, behavioral, emotional, and cognitive abilities; his or her perception of the situation; the chronicity of the situation; the child’s accessibility to a caregiver and ability to seek help; the child’s understanding of safety procedures; and/or the designated caregiver’s physical, emotional, or cognitive abilities. Despite

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best practices, childhood injuries happen. When momentary lapses of attention occur that lead to an injury, counseling regarding appropriate supervision may be the only necessary intervention (Hymel 2006).

Key Points • When evaluating neglect, consider the severity, chronicity, frequency, and context of neglect. • Different types of neglect include physical, emotional, medical, education, and inadequate supervision. • When neglect is suspected, the child needs a full history and physical exam with involvement of child protective services, law enforcement, social workers, and forensic interviewers where appropriate. The medical exam is an opportunity for diagnosis and to provide appropriate treatment. • Nutritional neglect is multifactorial and requires a thorough history and exam. Barring severe cases, treatment can be achieved through outpatient therapy with close outpatient follow-up for weight checks, food journals, and caregiver buy-in. • Neglect has lifelong neurodevelopmental consequences including epigenetic changes.

Summary and Conclusion Neglect is the most prevalent form of child maltreatment in the United States, and it is associated with poor neurodevelopmental outcomes. Neglect can result in language and communication delays, as well as features resembling autism. Neglect can also cause lifelong physical and mental health problems. Diagnostically, medical providers must determine the line between “good enough parenting” and neglect. When intimate partner violence is present in the home, children should always be evaluated for neglect.

Cross-References ▶ Implications of Maltreatment for Young Children ▶ Overview of Child Maltreatment

References Afifi, T. O., Sareen, J., Fortier, J., Taillieu, T., Turner, S., Cheung, K., & Henriksen, C. A. (2017). Child maltreatment and eating disorders among men and women in adulthood: Results from a nationally representative United States sample. The International Journal of Eating Disorders, 50(11), 1281–1296. https://doi.org/10.1002/eat.22783.

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Rosalyn E. Brownlee, Gail Benton, and Scott A. Benton

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dental Neglect Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Signs of Dental Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pathology of Dental Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Barriers to Recognition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recognition Requires Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

This chapter is an overview of dental neglect and its implications. Dental neglect is defined and proposed scales of assessment are explored. Broad consensus exists in scientific literature that untreated oral disease impacts an individual’s overall health. The purpose of this chapter is to increase recognition and reporting of dental neglect.

This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. R. E. Brownlee (*) · S. A. Benton (*) University of Mississippi Medical Center, Jackson, MS, USA e-mail: [email protected] G. Benton Sunnybrook Dentistry, Jackson, MS, USA © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_256

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Keywords

Dental neglect · DMFT index · Early childhood caries

Introduction Children and many vulnerable adults are considered dependents because they depend on their caretakers for food, clothing, shelter, supervision, nurturance, medical care, and education. Generally, neglect is defined as the willful failure of a caretaker to provide one of these seven necessary elements when reasonably able to do so. It is incumbent on the state to assist caretakers who cannot reasonably provide for their dependents. This chapter will focus on dental neglect and its implications.

Dental Neglect Definition The American Academy of Pediatric Dentistry (Definition of dental neglect 2017) defines dental neglect as the “willful failure of parent or guardian to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection.” The British Society of Paediatric Dentistry (Harris et al. 2009) further notes neglect “as the persistent failure to meet a child’s basic oral health needs, likely to result in the serious impairment of a child’s oral or general health or development. It may occur in isolation or may be an indicator of a wider picture of neglect or abuse.” Bhatia et al. (2014) in a systematic literature review of dental neglect found the main caretaker characteristics included failure or delay in seeking dental treatment and failure to follow advice or complete treatment. The American Academy of Pediatric Dentistry (Oral and dental aspects of child abuse and neglect 2017) delineated some additional factors needed to make the diagnosis of dental neglect: • “A child is harmed or at risk for harm because of lack of dental health care; • The recommended dental care offers significant net benefit to the child; • The anticipated benefit of the dental treatment is significantly greater than its morbidity, so parents would choose treatment over nontreatment; • Access to health care is available but not used; and • The parent understands the dental advice given.”

Signs of Dental Neglect It is important that all health professionals conduct a proper oral examination with each child’s encounter and question the caretaker’s attitudes and knowledge of oral healthcare. Dental health professionals are in a unique position to assess oral health

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(Harmer-Beem 2005; Richardson 2008). Dental neglect can be identified by considering a child’s pathologic oral findings and their caregiver’s role in those findings. A proper oral examination starts with a thorough medical history. All medical conditions, allergies, medications, hospitalizations, surgeries, and facial trauma should be documented. Oral hygiene is rated by the amount of plaque present on the teeth. After the teeth are cleaned, the mouth can be examined for pathology. Decayed, missing, filled, fractured, and discolored teeth are noted in the patient’s chart. The conditions of the gingiva and all other oral mucosa are evaluated. Bleeding, inflammation, purulent discharge, or discoloration of the oral mucosa can indicate poor oral hygiene, dental abscess, or systemic disease. If the patient is cooperative, dental radiographs can be taken to further diagnose any pathology. Dental neglect mostly manifests as dental caries and dental pain which by themselves may have serious consequences (see Table 1). Oral pathology exists on a severity continuum. There are no oral findings, even the most severe, that define neglect without the caretaker’s role being factored. The DMFT index is the oldest objective method to describe the amount of caries in a child. The index refers to the number of teeth that are (D) decayed, (M) missing, or (F) filled. A slight variant is the DMFS which counts the number of tooth surfaces that are decayed, missing, or filled. The difference between primary and permanent dentition is represented by lowercase “dmf” for the primary dentition. These indices however do not use radiographs in their score and therefore may underestimate the carious burden. There are some conditions that come close to independently defining Table 1 Consequence of neglect of primary teeth caries (Colak et al. 2013) Short term Pain Infection, e.g., abscess, cellulitis Poor appetite Disturbed sleep Emergency visits and possibly hospitalizations Loss of school days with restricted activity Reduced ability to learn and concentrate Need for extractions Need for treatment under general anesthesia Premature loss of primary molars predisposing to malocclusion Long term Poor oral health and dental disease often continue into adulthood Higher risk of new carious lesions in the other primary teeth and the succeeding permanent dentition Affect child’s general health, resulting in insufficient physical development especially in height and weight Increased treatment costs and time for parents Rare sequelae Sub-orbital cellulitis Brain abscesses Unexplained recurrent fevers Acute otitis media

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dental neglect. These include extensive early caries (Sillevis Smitt et al. 2017; Scorca et al. 2013; Valencia-Rojas et al. 2008), dental abscesses (Jenkins et al. 2018), dento-facial infections (Schlabe et al. 2018), and the need for extractions or general anesthesia (Kvist et al. 2014). However, the caretaker’s role is not assessed by these objective measures which limits their utility in defining dental neglect. There is a clear correlation that dental neglect and child maltreatment leads to a higher DMFT or DMFS index (Sillevis Smitt et al. 2017; Valencia-Rojas et al. 2008; Greene et al. 1994; Kvist et al. 2018; Keene et al. 2015; Badger 1986). Therefore, a high DMFT or DMFS score should lead to an exploration of dental neglect and other forms of child maltreatment. Thomson et al. (1996) studied seven statements posed as a five-point Likert scale (definitely no to definitely yes) to caregivers of children to obtain a dental neglect score. The statements were “1. Your child maintains his/her home dental care, 2. Your child receives the dental care he/she should, 3. Your child needs dental care, but you put it off, 4. Your child needs dental care, but he/she puts it off, 5. Your child brushes as well as he/she should, 6. Your child controls between-meal snacking as well as he/she should, 7. Your child considers his/her dental health to be important.” They found the dental neglect score addressed caretaker’s attitude and correlated with caries burden as measured by DMFS.

Pathology of Dental Neglect Focus on oral care can be seen as early as 5000 BC, and the idea of a toothbrush was first recorded in 3000 BC (Fischman 1997). Throughout history there is a general acceptance of oral care including breath, gums, and teeth. There are many factors that affect a person’s participation in oral care and interventions. Oral health can be impacted by water fluoridation status (Iheozor-Ejiofor et al. 2015), dental visit patterns, childhood feeding practices (Dilley et al. 1980), failure to clean teeth, oral bacteria, smoking, and trauma. Obvious dental disease, delay in seeking care, and failure to obtain care should heighten concern for neglect. Furthermore, dental neglect may be a sign of overall negligence and a possible indicator of child physical abuse. Dental caries is the most common chronic infectious disease of childhood and is the result of the combination of bacteria present in the mouth and sugar content of foods on tooth enamel (Photos 1 and 2). The most common bacterial causes of caries are Streptococcus mutans and Streptococcus sobrinus (Maguire et al. 2007). As sugar is broken down by bacteria, an acidic environment forms within the oral cavity. Consequently, tooth enamel is eroded, and teeth are left vulnerable to caries (Delli et al. 2013). Early childhood caries (ECC) is a worldwide problem that transcends economic development and can affect dentition even through adulthood. ECC is defined as “the presence of one or more decayed (non-cavitated or cavitated lesions), missing teeth (due to caries), or filled tooth surfaces in any primary tooth in a child 72 months of age or younger” (Suzuki et al. 2008;Tanzer et al. 2001). Socioeconomic status, single parent homes, parents with low education levels, being a

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Photo 1 2-year-old child. (Courtesy of Gail V. Benton, DDS)

Photo 2 Photograph of the maxillary arch of a 2-year-old child with nursing bottle caries and previous oral trauma as seen through an oral mirror. The maxillary left central incisor and the maxillary lateral incisors have severe dental caries. The maxillary right central incisor was avulsed 3 days prior due to a fall. Note the abrasion on the lip. The maxillary second molars have occlusal caries. The mandibular arch was complete and intact with no dental caries

member of ethnic or racial minorities, and living in poverty are all factors that have been associated with increased ECC. There is a significant correlation between ECC and sleeping with a bottle (Hallett and O’Rourke 2002). Other factors affecting caries formation include prolonged enamel exposure to human milk, fermentable carbohydrate content of food, high frequency of sugar intake coupled with prolonged retention in the mouth, and decreased intake of protective factors such as calcium, phosphates, and fluoride. If left untreated, dental disease in children can lead to lifelong consequences. As treatment is delayed, conditions may worsen and make treatment more difficult as well as increase the likelihood of poor outcomes. Oral health affects an individual’s growth and development, social interactions, ability to talk, ability to chew, and ability to taste foods. There are broader implications of dental neglect including poor

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school performance and lower quality of life (Fisher-Owens et al. 2017). Failure to recognize and intervene has a range of consequences for children: pain and suffering (loss of sleep, poor attendance at school, interference with playing and socializing, reduced quality of life), serious infection (endocarditis, mediastinitis, brain abscess, cavernous sinus thrombosis, Ludwig’s angina), future poor health, disability, and death (Akinkugbe et al. 2019; Bosch et al. 2019). Understanding oral examination is important for all healthcare providers, not just dental professionals. Though the majority of children do not have their first dental visit until age of 3 or after (Ivanoff and Hottel 2013), they have been seen by their primary care provider several times. Consideration should be given to missing teeth, caries, and traumatic injury, as well as normal development of teeth in order to fully assess oral health. Obtaining a full history regarding any injury is essential. Accidental injuries to the mouth are a common occurrence in childhood, but repetitive injuries warrant concern for neglectful supervision. It is important to understand the mouth’s role in maltreatment as the head and neck area is frequently targeted in abuse. Intraoral injury is a small percentage (2–7%) of these injuries, but should be identified as “sentinel injuries” in infants which warrant further investigation (Maguire et al. 2007). The most common maltreatment involving the mouth is physical abuse. Intraoral injuries are rarely observed but can include petechiae, bruising, lacerations, swelling, fractures, luxation injuries, and burns. The presence of a torn upper labial frenum has a high concern for abuse in individuals less than 5 years old (Maguire et al. 2007; Delli et al. 2013). Even in early childhood, identification of forced feeding injury and direct blows to the mouth may be identified. Though rare, oral manifestations of sexual abuse can also be seen on examination. Findings can include ulcers, mucosal injury, and petechiae. Gonorrhea can cause pharyngitis and gingivitis. Oral complications of HIV include oral candidiasis, recurrent ulcers, and herpes infection. Oral condyloma due to human papillomavirus has a nonspecific to concerning association with sexual contact/abuse. If sexual abuse is suspected, a report should be made to the appropriate agency, referral should be made for forensic examination, and complete sexually transmitted infection testing should be completed.

Barriers to Recognition Even with thorough oral examination, there are physical and psychosocial factors that can affect evaluation. Mouth tissue, or oral mucosa, heals quickly and sometimes without evidence of previous injury. Some obvious signs of injury, such as bleeding, stop quickly and can be missed if immediate care is not sought. Another important point to consider is a person or parent’s emphasis on dental examinations. There is evidence that women who experienced sexual abuse as a child have more dental problems, have greater dental fear, and are less likely to

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schedule regular dental care than those who did not report a history of abuse (Leeners et al. 2007). Individuals with higher ACE (adverse childhood event) scores had inadequate dental care as children as well as poor oral health as adults (Crouch et al. 2018; Akinkugbe et al. 2019; Bosch et al. 2019). Patient and parent understanding of how diet and hygiene affect oral health can also be a barrier. Those with limited access to dental care should be identified in order to provide information on available resources in their area. Cognitive bias and provider discomfort with oral examination may cause one to miss injury that is not seen without full exam. Available instrumentation and lighting can also be limiting factors. The lack of a real definition of dental neglect can also make providers hesitant to report. Improvement in education of oral health providers can increase recognition of abuse and neglect.

Recognition Requires Reporting Underreporting of maltreatment is well studied across healthcare professionals. In most of the industrialized world, healthcare professionals must comply with mandatory reporting laws. As mandated reporters, providers are obligated to report suspected abuse or neglect of children and vulnerable adults. Healthcare professionals should be knowledgeable about mandated reporting law for the regions in which they practice.

Prevention The promotion of oral health as with most public health preventions has three tiers: primary, secondary, and tertiary responses. Primary prevention is targeted at an entire population. With oral health, the most successful solution has been introducing fluoridated water and oral hygiene products. Fluoridated water has the advantage of not requiring individual initiative. Caregiver and general public education on how to avoid carious-causing situations also falls into this category. Education here focuses on avoiding cariogenic diets and nighttime bottle feeds coupled with supervised teeth brushing and flossing. Regular dental visits should start with the first eruption of teeth. The standard of care now includes preventive fluoride varnishes and pit sealants. These have shown great success by providing enamel protection without individual effort. Secondary prevention involves identifying those with poor oral health that have resource barriers. State-funded healthcare insurance for those of low socioeconomic means and proximate placement of dental clinics are the major methods in this tier. Tertiary prevention involves state intervention with identified maltreated and neglected children. The focus here is health provider education which improves recognition and reporting of dental neglect (Thomas et al. 2006; Raja et al. 2015; Gironda et al. 2010; Ivanoff and Hottel 2013; Shapiro et al. 2014; Jordan et al. 2012; Jessee and Martin 1998).

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Key Points • Oral hygiene has an impact on overall health. • Manifestations of oral neglect can be broad for children and adults. • It is important to assess the level of understanding about oral health a patient or guardian has before indicating neglect. • Providers across healthcare professions should be comfortable with oral examination. • Improving teaching in respect to recognizing abuse and neglect is important. • If abuse or neglect is suspected, it should be reported to the appropriate authority.

Conclusion Many factors affect an individual’s participation in oral health. Dental neglect in itself is an issue and may be an indicator of broader maltreatment. Every patient deserves thorough evaluation including oral examination. There is no exact scale to relate dental neglect across professions. The basis for appropriate oral examination begins with teaching at each level to recognize signs of abuse or neglect. The likelihood of a provider to report suspected maltreatment increases with their comfort level of recognition. Dental neglect can be prevented with teaching and intervention, which can then improve a patient’s overall health.

Cross-References ▶ Child Maltreatment: Mandated Reporting ▶ Overview of Child Maltreatment ▶ Sexual Abuse of Children ▶ The Nature of Neglect and Its Consequences

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Colak, H., Dülgergil, C. T., Dalli, M., & Hamidi, M. M. (2013). Early childhood caries update: A review of causes, diagnoses, and treatments. Journal of Natural Science, Biology, and Medicine, 4(1), 29–38. Crouch, E., Radcliff, E., Nelson, J., Strompolis, M., & Martin, A. (2018). The experience of adverse childhood experiences and dental care in childhood. Community Dentistry and Oral Epidemiology, 46(5), 442–448. Definition of dental neglect. (2017). Pediatric Dentistry, 39(6), 13. Delli, K., Livas, C., Sculean, A., & Katsaros, C. (2013). Facts and myths regarding the maxillary midline frenum and its treatment: A systematic review of the literature. QuintessenceInternational, 44, 177. Dilley, G. J., Dilley, D. H., & Machen, J. B. (1980). Prolonged nursing habit: A profile of patients and their families. ASDC Journal of Dentistry for Children, 47(2), 102–108. Fischman, S. L. (1997). The history of oral hygiene products: How far have we come in 6000 years? Periodontol 2000, 15, 7–14. Fisher-Owens, S. A., Lukefahr, J. L., & Tate, A. R. (2017). Oral and dental aspects of child abuse and neglect. Pediatric Dentistry, 39(4), 278–283. Gironda, M. W., Lefever, K. H., & Anderson, E. A. (2010). Dental students’ knowledge about elder abuse and neglect and the reporting responsibilities of dentists. Journal of Dental Education, 74(8), 824–829. Greene, P. E., Chisick, M. C., & Aaron, G. R. (1994). A comparison of oral health status and need for dental care between abused/neglected children and nonabused/non-neglected children. Pediatric Dentistry, 16(1), 41–45. Hallett, K. B., & O’Rourke, P. K. (2002). Early childhood caries and infant feeding practice. Community Dental Health, 19(4), 237–242. Harmer-Beem, M. (2005). The perceived likelihood of dental hygienists to report abuse before and after a training program. Journal of Dental Hygiene, 79(1), 7. Harris, J. C., Balmer, R. C., & Sidebotham, P. D. (2009). British Society of Paediatric Dentistry: A policy document on dental neglect in children. International Journal of Paediatric Dentistry, 28, e14–e21. Iheozor-Ejiofor, Z., Worthington, H. V., Walsh, T., O’Malley, L., Clarkson, J. E., Macey, R., et al. (2015). Water fluoridation for the prevention of dental caries. Cochrane Database of Systematic Reviews, 6, CD010856. Ivanoff, C. S., & Hottel, T. L. (2013). Comprehensive training in suspected child abuse and neglect for dental students: A hybrid curriculum. Journal of Dental Education, 77(6), 695–705. Jenkins, G. W., Bresnen, D., Jenkins, E., & Mullen, N. (2018). Dental abscess in pediatric patients: A marker of neglect. Pediatric Emergency Care, 34(11), 774–777. Jessee, S. A., & Martin, R. E. (1998). Child abuse and neglect: Assessment of dental students’ attitudes and knowledge. ASDC Journal of Dentistry for Children, 65(1), 21–24. Jordan, A., Welbury, R. R., Tiljak, M. K., & Cukovic-Bagic, I. (2012). Croatian dental students’ educational experiences and knowledge in regard to child abuse and neglect. Journal of Dental Education, 76(11), 1512–1519. Keene, E. J., Skelton, R., Day, P. F., Munyombwe, T., & Balmer, R. C. (2015). The dental health of children subject to a child protection plan. International Journal of Paediatric Dentistry, 25(6), 428–435. Kvist, T., Zedrén-Sunemo, J., Graca, E., & Dahllöf, G. (2014). Is treatment under general anaesthesia associated with dental neglect and dental disability among caries active preschool children? European Archives of Paediatric Dentistry, 15(5), 327–332. Kvist, T., Annerbäck, E. M., & Dahllöf, G. (2018). Oral health in children investigated by social services on suspicion of child abuse and neglect. Child Abuse & Neglect, 76, 515–523. Leeners, B., Stiller, R., Block, E., Görres, G., Imthurn, B., & Rath, W. (2007). Consequences of childhood sexual abuse experiences on dental care. Journal of Psychosomatic Research, 62(5), 581–588. Maguire, S., Hunter, B., Hunter, L., Sibert, J. R., Mann, M., Kemp, A. M., et al. (2007). Diagnosing abuse: A systematic review of torn frenum and other intra-oral injuries. Archives of Disease in Childhood, 92(12), 1113–1117.

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Oral and dental aspects of child abuse and neglect. (2017). Pediatric Dentistry, 39(6), 235–241. Raja, S., Rajagopalan, C. F., Kruthoff, M., Kuperschmidt, A., Chang, P., & Hoersch, M. (2015). Teaching dental students to interact with survivors of traumatic events: Development of a twoday module. Journal of Dental Education, 79(1), 47–55. Richardson, D. J. (2008). A reminder: Dentistry’s role in preventing child abuse and neglect. LDA Journal, 67(3), 30–32. Schlabe, J., Kabban, M., Chapireau, D., & Fan, K. (2018). Paediatric dento-facial infections – A potential tool for identifying children at risk of neglect? British Dental Journal, 225(8), 757–761. Scorca, A., Santoro, V., De Donno, A., Grattagliano, I., Tafuri, S., & Introna, F. (2013). Early childhood caries (ECC) and neglect in child care: Analysis of an Italian sample. La Clinica Terapeutica, 164(5), e365–e371. Shapiro, M. C., Anderson, O. R., & Lal, S. (2014). Assessment of a novel module for training dental students in child abuse recognition and reporting. Journal of Dental Education, 78(8), 1167–1175. Sillevis Smitt, H., de Leeuw, J., & de Vries, T. (2017). Association between severe dental caries and child abuse and neglect. Journal of Oral and Maxillofacial Surgery, 75(11), 2304–2306. Suzuki, N., Yoneda, M., Naito, T., Iwamoto, T., & Hirofuji, T. (2008). Relationship between halitosis and psychologic status. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics, 106(4), 542–547. Tanzer, J. M., Livingston, J., & Thompson, A. M. (2001). The microbiology of primary dental caries in humans. Journal of Dental Education, 65(10), 1028–1037. Thomas, J. E., Straffon, L., & Inglehart, M. R. (2006). Child abuse and neglect: Dental and dental hygiene students’ educational experiences and knowledge. Journal of Dental Education, 70(5), 558–565. Thomson, W. M., Spencer, A. J., & Gaughwin, A. (1996). Testing a child dental neglect scale in South Australia. Community Dentistry and Oral Epidemiology, 24(5), 351–356. Valencia-Rojas, N., Lawrence, H. P., & Goodman, D. (2008). Prevalence of early childhood caries in a population of children with history of maltreatment. Journal of Public Health Dentistry, 68(2), 94–101.

Section V Sexual Abuse of Children and Adolescents Ernestine Briggs, Theodore P. Cross, Amy Russell, Michelle Clayton, Javonda Williams, Stacie Schrieffer LeBlanc, Heather J. Risser, Viola Vaughan-Eden, and Victor I. Vieth

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Foundations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definition of Sexual Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Effects of Sexual Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Knowledge about many aspects of the sexual abuse of children has exploded over the last four decades. This chapter reviews definitions of child sexual abuse, how common is the abuse, factors increasing the risk for some children to be abused, what is known about people who sexually abuse youth, and the effects on children of early sexual abuse. Keywords

Child sexual abuse · Risk factors · Historical development · Effects · Sexual offenders · Prevalence · Incidence

This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. J. R. Conte (*) · J. Simon Joshua Center on Child Sexual Abuse, University of Washington, Seattle, WA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_100

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Introduction The sexual use of children and vulnerable humans by more powerful humans appears as old as human history. It is only in the last four decades or so that child sexual abuse (CSA) has received attention from the public and researchers. Indeed, until very recently a four-volume Encyclopedia on Interpersonal Violence would not have been possible. Today as this is written, a comprehensive treatment of the topic of childhood sexual abuse (CSA) itself would require multiple chapters, if not volumes. This chapter is intended to provide an overview of the subject, especially for new professionals and investigators. A comprehensive review of research addressing each topic in this chapter is not possible, although key references will be cited for the reader. Important research topics for future investigation will also be identified. A number of advanced topics in CSA will not be addressed here. These include psychotherapy with victims of CSA (see, e.g., Fitzgerald and Berliner 2018, and Briere and Scott 2014), pornography (see, e.g., Anderson 2017), sexual trafficking (see, e.g., Greenbaum et al. 2018), and others.

History Those reading this chapter to the Encyclopedia will no doubt wonder why it is important to give even a momentary thought to the history of the awareness and response to CSA. What seems more important is what is known now as this is being written and read. This is a reasonable question to ask. We will not labor long here on history, but we would submit to the reader that history tells us not only what is the foundation of what we know and believe today but may also illustrate how we have approached knowledge and practice in the past; perhaps at times for well-meaning purposes but with insufficient knowledge. Perhaps there are lessons to be learned going forward. First phase. There are no comprehensive histories of modern awareness of CSA. Legal scholar John E. B. Myers, in his important A History of Child Protection in America (Myers 2004), provides a good summary chapter on early developments. More recently, former FBI agent and long-time child abuse expert Ken Lanning, in his memoir Love, Bombs, and Molesters: An FBI Agent’s Journey (Lanning 2018), provides an excellent overview of some of the missteps and knowledge errors early in the field. (See also Herman 1992; Olafson et al. 1993; Costin 1992; and Gordon 1988.) As Myers (2004) and earlier Conte (1982 and 1991a) point out, Freud was among the first professionals to speculate about the adverse effects of adult sexual use of children. Conte notes that the first phase of professional development went from the late 1890s to the mid-1970s and was largely characterized by lack of awareness or focus on the wrong aspects of CSA. Freud’s speculations about the effects of CSA, his theory of fantasized sexual contact with adults, and his interest in repression, even though written about 100 years ago, provided an ancient straw man for authors to make interesting historical and other points. (See, e.g., Masson 1984.)

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While Freud never abandoned his interest in childhood sexual abuse and speculations about why he developed the theory that children’s fantasized sexual contact with adults was more important than the reality of abuse (e.g., fear of the reactions of others in Victorian Vienna or that because he harbored incestuous feelings for his daughter Anna whom he analyzed), a more balanced and perhaps more objective view of Freud is that his real error was basing statements on limited observation of 18 patients and on theory rather than research. Revisionist psychoanalyst Alice Miller pointed to the idea that humans bring their own personal histories and biases to a subject as emotional as CSA when she noted that Freud, being the father of psychoanalysis, never had the benefit of it (Miller 1984). CSA is inherently a subject which triggers strong emotions, has the potential of significant impacts on all involved, and is easy to allow personal biases to outweigh evidence. It is fortunate for the professional today that evidence is accumulating faster than in the past. As both Conte and Myers point out, CSA received only scattered attention from Freud’s time until the mid-1970s. Early research was concerned with whether there were genetic deformities resulting from children born from incest (see, e.g., Adams and Neel 1967), and also there were only scattered references to the effects of CSA (for review see Conte 1985a). For whatever reasons, professionals and the public largely ignored CSA, even though there were scattered references in the professional literature and newspaper accounts of sexual offenders being arrested and convicted. Arguably, modern rediscovery of childhood sexual abuse was not something professionals came to but rather the sensitivities of the rape crisis movement and attention to adult rape moved the public and then professionals toward the subject of child rape. Survivors of CSA appeared on national talk shows such as those of Phil Donahue or/and Oprah Winfrey, and by sharing their experiences, professionals began addressing CSA. Pioneer child abuse researchers Ann Burgess and David Finkelhor and advocate Sandy Butler responded to and expanded the emerging awareness (Burgess et al. 1978; Finkelhor 1979a; Butler 1978). Second phase. In the second period of CSA history from the 1970s to the 1990s or so, efforts might be characterized as discovery and missteps. As this chapter will illustrate, much was learned in this period. We will not dwell on the many missteps, but it is now clear that there were many beliefs that research subsequently proved to be false. These debunked beliefs include but are not limited to: Children never lie about being abused; incest is a family problem instigated as much by mother and daughter as father; sexual abuse is not really about sex, it is about power; incest in families is a love relationship gone wrong; anatomical dolls are sexually suggestive and lead to false reports of abuse; children who use dark colors in artwork or include phallic images in artwork have been sexually abused; a child’s behavior (e.g., acting out) proves sexual abuse; repression is the mechanism that leads to amnesia; young children cannot provide reliable reports of their experiences; longterm memories of abuse are inherently unreliable; the diagnosis of Parent Alienation Syndrome is supported by definite criteria which distinguish between children who reliably report abuse versus those who are led by their mother to falsely accuse a male; there are a large number of satanic cults worldwide sexually abusing and

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sacrificing babies; children in therapy playing Candy Land or Checkers who do not bring up abuse are not ready to talk about it; indeed, talking about trauma is not a good idea and the goal of therapy is to forget it; and so many more that it becomes overwhelming to think about the errors in practice made based on such beliefs. (For discussion see Conte 1982, 1991a, b.) This is not the place to argue why these errors were made. Certainly the desire to help on the part of many professionals and limited knowledge supported a reliance on what were not really tested ideas. A lag between knowledge development and putting knowledge in practice is common in many fields. There were personal motives (e.g., testifying in defense of adults accused of CSA or applying one’s favorite theory from previous work to CSA where the theory was untested in the new context) based on doing what was believed versus what was known to be correct. As a reader if you believe any of the above are accurate statements of knowledge, we urge you to do some independent research. It may be difficult for readers today to appreciate that, in the early period of rediscovery of CSA, there were serious discussions about whether CSA was a mental health problem or should be prosecuted (see Conte 1982 for discussion), whether criteria other than what a child said happened should be used to substantiate allegations of CSA (see, e.g., Conte et al. 1991), or whether CSA was associated with ill effects (see, e.g., Constantine and Martinson 1981). Many of the thinking and practice errors of the first several decades of awareness of CSA led to a backlash with well-meaning and some not-so-well-meaning critics of CSA responding (see Myers 1994). Some of the issues raised were driven by efforts to defend adults accused of sexual abuse whether they had research support or not (e.g., anatomically correct dolls stimulate children into making false reports) and others by research which demonstrated the errors in previous ideas. (For discussion see, e.g., Conte 1990, 1991b.) The good news for professionals entering and working in the field today is that research has exploded in the last two decades on many of the topics which make up modern understanding of CSA. The current historical period is characterized by the explosion of research on CSA and on its dissemination to the public and professionals. Notwithstanding this explosion, we may believe things today which tomorrow will be proven wrong. Indeed, professional practice with vulnerable children and adults abused in childhood demands that all ideas and practices are approached with the same caution and search for data that any potentially powerful belief or practice deserves.

Foundations Definitions. Defining child sexual abuse would seem at first thought to be easy. It involves some kind of abusive sexual contact with a child. Early definitions described tricked, coerced, or manipulated sexual contact with a child and a person 5 or so years older. Over time the inadequacy of this definition became clear as it was understood that many children are abused by a peer who is not 5 years older. Also,

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what is sexual can be difficult to determine in some situations. Direct contact between the parts of the body associated with sex and the body of an older person is relatively easy to identify. Wrestling which allows for disguised contact, entering the bathroom while the child is bathing, and other situations can be more difficult to identify as sexual abuse, at least without knowing how often the behavior takes place. Some definitions of what constitutes sexual abuse refer to the “context” or intent of the adult. For example, in a thoughtful discussion Haugaard (2000) points out that abuse definitions are on a continuum from where there is agreement that the act is abusive (intercourse with a child) to less clear (e.g., a parent bathing with a child). Wikipedia (Child sexual abuse, n.d.) currently defines CSA as follows: “Child sexual abuse, also called child molestation, is a form of child abuse in which an adult or older adolescent uses a child for sexual stimulation. Forms of child sexual abuse include engaging in sexual activities with a child (whether by asking or pressuring, or by other means), indecent exposure (of the genitals, female nipples, etc.), child grooming, child sexual exploitation or using a child to produce child pornography.” (https://en.wikipedia. org/wiki/Child_sexual_abuse).

Intent can be difficult to determine and may only be apparent over time, such as with the stepfather who routinely “accidentally” enters the bathroom while his stepdaughter is showering. Young children may engage in what on the surface appears to be “sexual abuse” such as inserting a stick into the vagina or anus of another child or repeatedly pulling down the pants of other children, but the underlying motivation for the behavior may not be clear. It is also important to understand how the child victim perceives the act. The child who was hurt by the stick may understand this act more as a physical assault that hurt than a sexual one and labeling the act as sexual abuse may either have no meaning to the young child or add uncertainty to the child’s understanding of the aggression. In a recent review of definitions in professional, legal, and policy literatures, Mathews and Collin-Vézina (2019) suggest that future definitions should be based on four criteria: the person must be a child, true consent must be absent, acts must be sexual, and acts must constitute abuse. As the authors note, each criterion is in itself complex. Following the criteria suggested by the authors allows each reader to consider and professionals to seek consensus on how to define each. Consent, especially “true” consent, can be difficult to determine since the point of grooming or conditioning of the child by the more powerful person is inherently about getting the child to go along with the abuse or to believe the sexual contact was the child’s idea. Finkelhor (1979b) long ago argued that a child cannot give informed consent to sexual abuse because the child often does not understand what is being consented to and does not have the true power to say no. Indeed, some victims locked in ongoing abuse situations may initiate sexual contact as a way of managing the anxiety associated with not knowing when the abuse is going to happen. Victims frequently believe they have given consent by not disclosing after the first incident of abuse or after the grooming has progressed, and the contact has become more sexual.

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Terms such as “abuse,” “exploitation,” “harm,” and even “sexual” are inherently difficult to define. They carry assumptions about the potential impact of behaviors, about inherent values associated with various behaviors (e.g., school-age children should not masturbate in public), and what behaviors deserve adult attention and potential intervention. In the early stages of professional awareness of CSA, the internet was nonexistent. Today it has mixed implications for professional and public awareness. A recent webpage (Tracy 2019, https://www.healthyplace.com/abuse/child-sexual-abuse/ what-is-child-sexual-abuse) states:

Definition of Sexual Abuse In its simplest form, child sexual abuse is any sexual encounter that occurs between a child and an older person (as children cannot legally consent to sexual acts). This abuse may involve contact, like touching or penetration. It also includes non-contact cases, like “flashing” or child pornography. However, in practice, there are actually two working definitions of child sexual abuse. One definition of childhood sexual abuse is used by legal professionals while the other is used by clinical professionals, like therapists. In the realm of legal definitions, both civil (child protection) and criminal definitions exist for child sexual abuse. Federally, the definition of child sexual abuse is contained within the Child Abuse Prevention and Treatment Act. Sexual abuse is defined to include:1. • “(A) the employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or. • (B) the rape, molestation, prostitution, or other forms of sexual exploitation of children, or incest with children;. . .”. The age under which one is considered a child varies by state and sometimes an age differential between the perpetrator and the victim is required. Clinical Definition of Child Sexual Abuse. Clinicians, like psychiatrists and psychologists, though judge childhood sexual abuse more on the effect it has on the child and less on a cut-and-dried definition. The traumatic impact is generally what clinicians look for in cases of sexual abuse. (Read about: Effects of Child Sexual Abuse on Children). A clinician often considers the following factors when differentiating abusive from non-abusive acts: • Power differential – wherein the abuser has power over the abused. This power may be physical or psychological in nature. • Knowledge differential – wherein the abuser has a more sophisticated understanding of the situation than the abused. This may be due to an age difference or cognitive/emotional differences.

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• Gratification differential – wherein the abuser seeks gratification for themselves and not the abused. This extended discussion of what CSA is certainly reflects ideas developed and confirmed by the experience of victims and survivors. The notion of the differentials between victim and offender is one of these. Legal definitions and clinical definitions may be different and serve different purposes. This webpage is correct that therapists often look at the effects of CSA but including this in a section on definitions confuses the acts which make up CSA and the effects which may or may not be present in any given case. Effects, harms, damages, and symptoms resulting from CSA are not helpful in defining what CSA is. Not all victims will experience the same effects, not all effects are present in a victim’s life at any one time, and many of the “effects” of CSA are also the effects of any number of other negative experiences. In a seminal research effort, Giovannoni and Becerra (1979) surveyed a large sample of professionals and members of the public concerning how they defined child abuse. The resulting categories of abuse and differences between various groups may or may not be directly relevant to today’s world but the method deserves careful consideration. Future research and practice would be aided by following the line of thought outlined by Haugaard (2000) and Mathews and Collin-Vézina (2019), and developing a taxonomy of behaviors perhaps simply defined as sexual behaviors/situations which children may be exposed to or engaged in. Behaviorspecific descriptions of experiences or acts would eliminate confusion over terms such as abuse, exploitation, and harm. Moral/ethical judgments and research-based consequences of the behaviors (e.g., is young children’s viewing of pornography harmful or not) could be separate issues. Agreement on a taxonomy of types of CSA would be a great aid to future research and practice in the area. Prevalence. Among the oldest issues beginning in the rediscovery and missteps phase in CSA professional history and in many ways continuing to this day is that of how large a problem CSA is. Prevalence describes the rate of occurrence of some characteristic in the general population. Arguments for responding to a problem, funding of responses, and justifying attention to a problem are often made based on how many people experience the problem. From the very beginning, studies disagreed over the lifetime exposure rate of people to CSA. In a 2013 review, Barth and colleagues report that results from 55 studies in 24 countries report prevalence estimates for CSA from 8% to 31% of girls and 3% to 17% of boys (Barth et al 2013). Earlier, in a review of 65 studies, Pereda, Guilera, Forns, and Gómez-Benito (Pereda et al. 2009) report overall rates of 19.7% for females and 7.9% for males. Finkelhor et al. (2009a) report results on a nationally representative sample of youth aged 0 to 17 who were interviewed by telephone and found lifetime prevalence of any sexual victimization to be 12.2% in girls and 7.5% in boys. In the same year, Hébert et al. (2009) report on a telephone survey of a representative sample of adults in Quebec and report prevalence rates of 22% for women and 9.7% for men. Of interest, 57% delayed disclosure for 5 years or more. In 2007 Basile, Chen, Black, and Saltzman report results from a national telephone survey conducted between

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2001 and 2003 which found lifetime forced sex prevalence rates at 10.6% for women and 2.1% for men (60.4% of females and 69.2% of males report being forced to have sex before turning 18) (Basile et al. 2007). Widely different estimates tend to create a sense of disbelief in the public and policymakers. The reasons for different rates have been suggested for some time. Bolen and Scannapieco (1999), in a review of prevalence studies, suggest the number of questions asked to identify CSA, the year the study was completed and the number of female respondents (more respondents lower prevalence rates) are all associated with the resulting prevalence rate reported in the study. Peters et al. (1986) argue that the definition of abuse, the number of questions asked, the method of data collection (paper and pencil surveys, telephone, or face-to-face interviews) impact prevalence rates. (See also Gorey and Leslie 1997.) In an interesting study, Bagley and Genuis (1991) compared computerized versus paper surveys. Although the data were collected 6 years apart, the computerized questionnaire yielded a prevalence rate of 14% compared to the printed questionnaire rate of 8.2%. Roosa et al. (1998) compared different measures of incidence (dichotomous measures, measures that took into account severity, and measures that included or excluded similar-aged peers as offenders) and found that the choice of measure resulted in up to a 300% difference in incidence rates. More recently, Goldman and Padayachi (2000) have argued that a host of methodological factors may impact prevalence rates, including the time period and awareness in that time, age limits defining childhood, definitional inconsistencies, and the number and types of questions. In an important empirical effort to understand variation in prevalence rates, Prevoo et al. (2017) identified moderator effects found in previous meta-analyses on the self-reported lifetime prevalence of child sexual abuse (and other forms of abuse) in international studies. Results indicate that boys in low-resource countries report higher prevalence rates. For females, smaller sample sizes report higher prevalence and also for females broader definitions result in higher prevalence rates. Paper and pencil surveys are associated with higher prevalence rates, lower rates for computer administered, and intermediate rates for face-to-face interviews. Although Finkelhor et al. (2005) report that very few respondents in their telephone survey refused to answer a question, it is also known that some respondents may report that they were not abused even though they were because they do not recall the abuse (Williams 1994). Some individuals with documented medical findings of abuse in childhood later deny that they were abused when asked (see Williams 1994; Lawson and Chaffin 1992). There is a disconnect between research on prevalence and research indicating that some childhood victims of sexual assault either as children or later as adult survivors do not report the abuse. Potential reasons vary from not recalling it, fear of stigma associated with sex and abuse, not wanting to hurt loved ones, or other unknown reasons. While the exact number of victims who cannot or do not report CSA is not known, it is clear that the numbers are sufficient to require consideration in trying to understand prevalence rates. As noted above, there is reason to believe that the year of publication of incidence studies is associated with the prevalence rate, which may be a proxy measure of the change in cultural or social norms and views of CSA and

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reporting. Certainly the #MeToo movement and widespread media coverage of Catholic, Boy Scout, and sporting organizations with large numbers of victims may be having an impact on willingness to report CSA. We are aware of no research on public attitudes and understanding of CSA that may impact disclosure and support for victims who do disclose. Nor are we aware of any analysis of how these attitudes and knowledge may have changed over the decades of modern awareness. Such research could be invaluable in improving the science of our field and in understanding attitudes that may impact funding of programs, juries who hear cases involving CSA, and indeed child and adult victims themselves. We are not the first to call for methodological research (see, e.g., Pereda et al. 2009) on how best (e.g., paper and pencil, computer, telephone, in-person interviews with matched or unmatched interviewer-interviewee pairs) to ask respondents about abuse histories, how stable are positive or negative responses (e.g., over a 12-month period), and what factors impact reporting of CSA, including socioeconomic status, ethnicity, perceived stigma associated with CSA, and mental health symptoms. The methodological issues faced in determining prevalence rates for sexual abuse are similar to those faced in other fields conducting surveys and evaluating lifetime experiences. Greater collaboration across fields facing similar methodological issues should be encouraged. Research would be useful with survey respondents to learn how they react to personal questions and if their responses would have changed if contacted again after a time to think about their experiences. The hallmark of a mature science is research on how to conduct research in that area. We have a long way to go in the CSA field in this regard. Decline in reports. A related issue to understanding the prevalence of CSA is the observation that rates are declining. Finkelhor and Jones et al. (2012) have argued that both official child abuse reports, but more interestingly a number of self-report surveys of adolescents, have all demonstrated a decline in reports. As reported by Finkelhor and Jones, these declines are substantial. For example, the National Incidence Studies of official reports show a 47% decline. The National Crime Victimization Surveys show declines from 1993 to 2008 of 69%. The National Survey of Family Growth from 1995 to 2008 reports a 39% decline. From 2017 to 2018 however, recent evidence of official reports from the National Child Abuse and Neglect Data System (NCANDS) shows a marked increase (6%) for the first time in more than 15 years (Finkelhor et al. 2020). While Finkelhor et al. (2020) do not speculate as to the reasons behind this increase, they report that longer-term trends are more telling than year-to-year changes, which “may or may not represent something enduring.” Overall, NCANDS data shows a 62% decline between 1992 and 2018 (Finkelhor et al. 2020). These are widely different rates of decline which cause some questioning as to what extent methodological or other issues may account for the variations. That all but one of the surveys noted by Finkelhor and Jones et al. (2012) show declines does point to an interesting question (the National Survey of Adolescents found a nonsignificant decline for girls and a non-significant increase for boys between 1995 and 2005). At the very time that CSA is receiving increasing attention, and a large number of adults are coming forward to describe abuse in childhood, why are the data showing a decline? (See Finkelhor and Jones 2004.)

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Finkelhor and Jones (2006) have a well-argued discussion of the decline and note a general decline over the same period in other crime statistics. Discussing possible explanations for this decrease, the authors suggest that it may be the increasing availability of psychotropic medications over the same time period as the decline that account for at least some of the decline. This is not a particularly convincing explanation since it is unclear that any mental condition linked to offending is successfully treated by medication (e.g., depression appears unrelated to sexual offending). Of some concern is that the most reliable data relied upon in thinking about the decline are adolescent self-report surveys. The factors impacting adolescents might be different from those impacting children. To be sure, if there has been a decline it would be helpful to more clearly identify the factors accounting for the declines and do more of whatever it was that was associated with the decline. Thoughts about whether there is a real or only an apparent decline also tends to detract from the more basic fact which is a very large number of children and youth continue to be sexually abused. Risk factors. It has long been recognized that offenders do not abuse every child with whom they have contact. In addition, whatever the actual prevalence rate is, not all children are sexually abused in childhood. Hence there is considerable value in identifying factors specific to the child or environment which places that child at increased risk for experiencing CSA. Typical of research on most topics, CSA research has not always identified the same risk factors. Research by Finkelhor and Asdigian (1996) based on the National Youth Prevention Study identified risk factors pertaining to the environment (risky behavior such as running away from home, getting drunk, and carrying a weapon to school) and those targeting congruence (vulnerability) (being a female, being older, experiencing psychological distress). More recently, Butler (2013), using data from the Panel Study of Income Dynamics, identified risk factors for sexual assault including relatively lower income; lower maternal education; lower achievement scores in children; being in special education; and family factors, including absent biological father or mother or lack of caregiver warmth. Pérez-Fuentes et al. (2013), in a large national study of more than 34,000 adults surveyed in 2004–2005, identified risk factors for CSA, including parent with substance abuse disorder; child physical abuse, maltreatment, or neglect; lower levels of perceived family support; a previous history of CSA; being Black or Native American versus being White; being widowed, separated, or divorced versus married; having public insurance versus private insurance; less likely to be males, Asian, foreign-born, or have completed high school. One of the problems with surveying adults to identify risk factors is that some of the factors which distinguish adults who have CSA histories from those who do not may actually be the results of, or caused by, CSA. In a 2001 review of 11 research reports and 1 book, Black et al. (2001) identified risk factors pertaining to perpetrators (less educated, poorer, extrafamilial victims, emotionally needy) and victim characteristics (lower family income, lower parental occupation status, single- or stepparent families, poor parent-child relationships [especially mother-daughter], parents less satisfied with parenting, parents more likely to leave child at home without adequate supervision).

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Most recently, in an impressive intellectual achievement, Assink et al. (2019) completed a meta-analysis of Western research completed between 1980 and 2017. They report that 765 risk factors were identified and classified into 35 risk domains, 23 of which showed significant effects through a series of three-level meta-analyses. These 23 risk factors were organized into the following 7 “risk themes”: (1) prior victimization of the child and/or their family members, for which the strongest effects were found (i.e., prior CSA victimization of the child and/or siblings, prior victimization of the child other than child abuse, prior or concurrent forms of child abuse in the child’s home environment, a parental history of child abuse victimization), (2) parental problems and difficulties (e.g., intimate partner violence between the child’s parents; other parental relationship problems; parental substance abuse; psychiatric/mental or physical problems of parents; a low level of parental education), (3) parenting problems and difficulties (i.e., low quality of parent-child relation including low parental attachment, parental overprotection, low levels of parental care/affection, and low parenting competence), (4) a nonnuclear family structure (i. e., growing up in a nonnuclear family, a child having a stepfather); (5) family (system) problems (i.e., problems in functioning of the family system, social isolation of the family or the child, a low family socioeconomic status, six or more moves/ resettlements of the child and family), (6) child problems (i.e., physical and/or mental chronic condition, using drugs or engaging in delinquent behavior), and (7) child characteristics (i.e., a low level of social skills, frequent use of the Internet). The strongest effects were found for prior victimization of the child and/or the child’s family members. Strong effects were also found for prior victimization (other than child abuse) or concurrent forms of child abuse in the child’s home environment and parental history of child abuse victimization. The most frequently cited risk factors in included studies were prior or concurrent forms of nonsexual child abuse in home, nonnuclear home excluding having a stepfather, being female, parental mental/psychiatric or physical problems, and low family SES. Some research has suggested that children with disabilities are at an increased risk (Little 2004; Jones et al. 2012; Hershkowitz et al. 2007). Sullivan and Knutson (2000) report on a large population-based study of children in a single school district over a single year. Results indicate children with disabilities were 3.4 times more likely to have been abused than peers without disabilities. In a review, Westcott and Jones (1999) reviewed research dating as far back as the 1960s and report that prevalence of CSA in children with disabilities varied from 4% to 83%. Factors contributing to abuse included dependency, institutional care, and child communication difficulties. In a more recent review, Govindshenoy and Spencer (2007) could find only four studies which met their criteria for inclusion and indicate the evidence for a connection between disability and increased CSA is weak. Two recent meta-analyses examined the prevalence and risk of violent victimization among people with disabilities (Hughes et al. 2012; Jones et al. 2012). The study by Hughes et al. (2012) reviewed evidence from 21 studies with adult samples. It found that the overall odds ratio (OR) for violent victimization among adults with disabilities (any type of disability) as compared with adults without disabilities was

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OR ¼ 1.5. Thus, an adult with a disability is 1.5 times more likely to be victimized than an adult without a disability. Research in this area is particularly difficult. Some disabilities make directly questioning the potential victim impossible or impractical. There may be differences in persons with disabilities besides their disability which may be linked to increased risk for CSA (e.g., institutional care, personal care of an intimate nature by nonrelated adults, poverty, and isolation). It also appears, with notable exceptions, that persons with disabilities have not been a major focus of CSA research. For example, it does not appear that surveys of prevalence in the general population screen for disabilities. The lack of large representative samples of individuals with and without disabilities limits a clear appreciation of the risk for CSA in this population. Nonetheless it should be understood that any vulnerability, whether physical, emotional, social, or otherwise, does place the child at risk if that child comes in contact with a predator. Another potential risk factor receiving some attention is LGBTQ status. Roberts et al. (2012) report on a large longitudinal cohort of youth. Gender nonconformity was associated with an increased risk for abuse (all forms). Andersen and Blosnich (2013), in a multistate probability-based sample, note that compared to heterosexual peers, gay/lesbian respondents had twice the odds of CSA and bisexual peers had nearly three times the odds. Balsam et al. (2010) examined a group of LGB adults they characterize as diverse (78% of the sample was White). Higher rates of CSA were reported among Latino/a and African American respondents as compared to Asian and White respondents. In a meta-analysis, Friedman et al. (2011) looked at adolescent school-based studies comparing the likelihood of childhood abuse (including CSA) among sexual minorities versus heterosexuals. The meta-analysis yielded 17 studies that satisfied inclusion criteria, plus an additional 37 studies that were added from data sourced from the Youth Risk Behavioral Surveillance Survey (or a similar survey with respect to the sample and questions asked). Analyses of childhood sexual abuse were based on 26 school-based studies in 11 geographic areas. Overall, sexual minority participants were 3.8 times more likely to experience CSA compared to heterosexuals. Compared to heterosexual adolescents, sexual minority adolescents were on average 2.9 times more likely to report CSA. Mean prevalence among females was 40.4% for bisexuals, 32.1% for lesbians, and 16.9% for heterosexuals. Mean prevalence among males was 24.5% for bisexuals, 21.2% for gays, and 4.64% for heterosexuals. Potential moderators of childhood sexual abuse were also examined. Gender was found to moderate the association between sexual orientation and childhood sexual abuse: compared to heterosexual males, sexual minority males were 4.9 times more likely to experience CSA, and compared to heterosexual females, sexual minority females were 1.5 times more likely to experience CSA. Rothman et al. (2011) report on a review of 75 studies on the prevalences of CSA and lifetime sexual assault among gay or bisexual men and lesbian or bisexual women. This review encompassed a total of 139,635 respondents over the various studies. Mean estimates of CSA among LGB individuals was found to be 22.7% for men (versus 30.4% lifetime sexual assault in LGB men and 2–3% lifetime sexual

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assault in general population men) and 34.5% in women (versus 43.4% lifetime sexual assault in LGB women and 11–17% lifetime sexual assault in general population women). Race and ethnicity in CSA have been understudied although attention was called to these factors by the pioneering work of Wyatt (1985) and Wyatt (1990), who suggested that disclosure rates are influenced by a number of factors and that race/ ethnicity may contribute only a small degree to these differences. Fear of disclosure does not appear limited by racial/ethnic group. In a review, Kenny and McEachern (2000) point to a number of methodological problems in research on race and ethnicity. The use of terminology to classify different racial/ethnic groups poses a serious methodological issue, as group classifications (“ethnic lumping”) vary across literature and may obscure factors critical to understanding CSA in particular populations. Additional issues in the literature examining racial/ethnic differences in CSA include the use of small sample sizes and retrospective self-reports of abuse. The authors make some observations from the existing literature (described below) but caution against any definitive conclusions as more cross-cultural research is needed. In terms of prevalence and incidence, findings were inconsistent regarding whether rates differ or are the same by race/ethnicity. Possible methodological differences contributing to differing estimates include (a) small sample sizes, (b) whether a sample is representative or not (cited representative studies found people who are Black to be overrepresented in estimates, while cited unrepresentative studies found people who are Black underrepresented), and (c) underreporting by race/ethnicity (which is suggested to occur in Asian American populations). There is a lack of evidence distinguishing whether race/ethnicity is a risk factor for abuse or if it is better explained by socioeconomic status. With regard to mothers’ responses to CSA disclosures, Black mothers seem to be more supportive to child disclosure than White or Hispanic mothers, while Asian and Asian American parents are found to be unsupportive of child disclosures and unlikely to believe or report abuse. In terms of severity of abuse, there is some evidence that Black youth experience higher rates of penetration compared to White and Hispanic youth, but studies are inconsistent with how they measure severity. A recent methodologically superior study (Newcomb et al. 2009) examined a community sample of youth ages 16 to 19 in Los Angeles. This study explores prevalence and psychosocial consequences of CSA in a community sample of 223 (Latino n ¼ 132; White n ¼ 54; other n ¼ 27). Overall prevalence of CSA was found to be 38.1%, with significantly higher rates among females than males (45.5% versus 24.4%; p < 0.01); Latinos than Whites (44.4% vs. 27.8%; p < 0.05); and Latinas versus Latinos, White females, and White males (54.2% vs. 23.9%, 28.1%, 27.3%; p < 0.001). Perpetrators of males were 52.9% female, and perpetrators of females were 91.9% male. The majority of participants were abused by one perpetrator (62.1% of females and 52.6% of males); however, several participants reported being abused by four or more perpetrators (7.6% of females and 15.8% of males). The search for factors in the child or environment (especially the child caring environment), which increases risk for CSA, is an important goal. While prevention

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efforts toward improving conditions which negatively impact child and family development are not necessarily major priorities of our society, one can hope that advocacy and political change will make them more so. From a social justice if not a moral/ethical perspective, providing resources to children who are at increased risk seems to be a call to professionals and the public. This is especially true because there seems to be an emerging consensus in the risk factor research that conditions impacting parenting are critical risk factors. Nonetheless, it is also important to appreciate that all children are inherently vulnerable, and children from privileged homes are also abused. Efforts to “harden the target” and make for child safe environments (see discussion below) should not be ignored or weakened in meeting the real needs of vulnerable children and families. The argument that we cannot do it all results in some set of children being left at greater risk. Adult sex offenders and youth with illegal sexual behavior problems. Perhaps no other aspect of CSA has inspired more controversy and confusion than that of sex offenders. While news accounts of “perverts” and “predators” can be found in newspapers from the 1900s, stereotypes of men in trench coats persist. Sex offenders tend to be monolithically hated and vilified. But one’s perception of an individual who offends may be complicated when that person is found to be a known member of our families, churches, youth groups, or other places that are familiar. It is now understood that the vast majority of people who sexually abuse children are someone the child knows. Official reports known to police have shown that nine in ten children who were sexually abused were victimized by an acquaintance or family member (Finkelhor and Shattuck 2012; Bureau of Justice Statistics 2000). Acquaintances might include peers or persons ostensibly in a position of care for the child, such as doctors, sports coaches, or religious leaders, as high-profile cases reported by the media have shown in the last two decades. Data from official reports have demonstrated that acquaintances constituted the largest group of sex offenders against youth (58%), followed by family members (33–34%), while strangers made up only 4–7% of offenders (Finkelhor and Shattuck 2012; Bureau of Justice Statistics 2000). Juveniles themselves have been found in official reports to be responsible for more than one third (35.6%) of sexual offenses committed against youth (Finkelhor et al. 2009b). Knowledge has progressed over the period of modern awareness of CSA from early focus on incest offenders to a broader view (see Conte 1982). Knowledge was significantly advanced by pioneering efforts of Gene Abel, Judith Becker, and their colleagues. Rigorous research on a sample of identified sexual offenders operating under a Certificate of Confidentiality (which was thought to increase the reliability of self-report data) conducted by these researchers over the 1980s challenged long-held beliefs about sexual offenders. Abel et al. (1988) reported that 49% of incestuous fathers and stepfathers abused children outside of the home, significantly challenging the idea that incest was a family problem. Eighteen (18) percent had raped adult women at the same time as they were abusing children. Another significant finding was that incestuous offenders demonstrated sexual arousal to children in laboratory assessments (Abel et al. 1981). Other research in this same area furthered the

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understanding that at least in part sexual abuse of children was a sexual problem and not a more significant emotional problem disguised as sexual. (For discussion of these early ideas see Conte 1991b.) Early research led Conte (1985b) to suggest a functional view of sexual offending against children which summarized the components of adult sexual use of children as denial; sexual arousal/interest; sexual fantasies; cognitive distortions, which minimize or rationalize sexual use of children; social skills deficits; and other problems. Since that time, there has been an increasing awareness that offenders are a heterogeneous group, and it is not known to what extent these components are present in all sex offenders or, more importantly, if there are other components more relevant to understanding offenders. Is an adult engaged in routine sexual abuse of a minor presenting with the same important components that make up the motivation for such behavior as a young child who inserts a stick into the vagina or anus of a same-age peer? Research that leads to understanding the various aspects of functioning which lead a human to sexually abuse another human would be of considerable value. This is in no way to suggest that research on factors associated with the development of people who sexually offend against youth is not important. Clearly it is. But the factors which maintain a problem may be different than those that lead to the onset of the same problem. Much of the research on sexual offending has focused on etiology and adolescents. Although illegal sexual behavior problems in youth have long been recognized as an aspect of CSA, it has become increasingly clear that many children are abused by peers, so it is worthwhile to understand the youth who abuse. Researchers have also referred to this group as “adolescent sex offenders,” a term which has been critiqued as developmentally inappropriate and for leading to responses that favor arrest over intervention, increased stigma, and a belief that the youth is “beyond” treatment (Silovsky, J., personal communication, April 30, 2020). The search needs to focus on what are the same and different between youth with illegal sexual behavior problems and other typologies of people who sexually abuse children. Today after decades of research and practice, it is safe to say that the sexual use of children is a behavior that peers, older adolescents, and adults engage in with some frequency. Like all behaviors it is not determined by one or even one set of factors. It is also clear that interest in whether incest offenders are somehow different persists. A recent review by Seto et al. (2015) of 78 samples of offenders in the USA and Canada indicate in their analysis that intrafamilial offenders were significantly lower on variables such as antisocial tendencies (e.g., criminal history, juvenile delinquency, impulsivity, substance abuse, and psychopathology) and atypical sexual interests (e.g., pedophilia, other paraphilias, and excessive sexual preoccupation). They also showed lower offense-supportive attitudes and beliefs, emotional congruence with children, and interpersonal deficits. They also were more likely than nonfamily offenders to have experienced sexual abuse, family abuse or neglect, and poor parent-child attachments. A number of studies have compared sex offenders with non-offenders. For example, Whitaker et al. (2008) summarize results from 89 studies published between 1990 and April of 2003. Risk factors were classified into one of the

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following six broad categories: family factors, externalizing behaviors, internalizing behaviors, social deficits, sexual problems, and attitudes/beliefs. Sex offenders against children (SOC) were compared to three comparison groups identified within the 89 studies: sex offenders who perpetrated against adults (SOA), non-sex offenders, and non-offenders with no history of criminal or sexual behavior problems. Results for the six major categories showed that SOC were not different from SOA other than showing lower externalizing behaviors. Sex offenders against children were somewhat different from non-sex offenders, especially with regard to sexual problems and attitudes. Sex offenders against children showed substantial differences from non-offenders with medium-sized effects in all six major categories. In short, sex offenders against children are different from non-sex offenders and non-offenders but not from sex offenders against adults. Other investigators have reviewed research examining emotional congruence between offenders and children (see McPhail et al. 2013). Thirty studies on emotional congruence with children in sex offenders against children were included in a random effects meta-analysis. Extrafamilial SOC – especially those with male victims – evidenced higher emotional congruence with children than most nonSOC comparison groups and intrafamilial SOC. In contrast, intrafamilial SOC evidenced less emotional congruence with children than many of the non-SOC comparison groups. It has long been thought that one approach to prevention would be to increase empathy, especially in males, for children and vulnerable adults. You cannot hurt a person with whom you have an empathetic connection, so the argument goes. Increased interest in adolescents with illegal sexual behavior problems has resulted in a number of reviews. Some adult offenders exhibit illegal sexual behavior problems when they are adolescents. The factors associated with the onset of a behavior like CSA may be different from the factors that maintain it after years of engaging in the behaviors. In describing the following studies, we have used their own terms to describe youth with illegal sexual behavior problems. This includes the use of “adolescent sex offenders” which is a contested term in the field as previously stated. An appropriate discussion of alternative and person-centered terms to describe adolescents deserves attention but is beyond the scope of this chapter. Certainly, definitions of sexual behavior that harms others are extremely important in communicating to all parties involved and professionals the value, meaning, and impact of the behavior. Seto and Lalumière (2010), in a particularly thorough review of studies with adolescent sexual and nonsexual offenders, note that many of the assumed differences (exposure to nonsexual violence, family relationship problems, social incompetence, conventional sexual experiences, and antisocial attitudes and beliefs) were not factors distinguishing between sexual and nonsexual adolescent offenders. Atypical sexual interests did distinguish between sexual and nonsexual offenders. Atypical interests included pornography, sex with animals, or sex with very young children. In an earlier review, Veneziano and Veneziano (2002) described adolescent sex offenders as a heterogeneous population with respect to onset of perpetration, age of victims, involvement of psychological coercion, and involvement of physical violence. Frequently described characteristics of adolescent

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sexual offenders include a history of severe family problems; separation from parents and placement away from home; experiences of sexual abuse, neglect, or physical abuse; social awkwardness or isolation; academic and behavioral problems at school; and psychopathology. Some evidence suggests that developmental trauma may be more common in juvenile than adult offenders (e.g., experiences of physical abuse in 25–50% of juvenile sex offenders). Generally, victims are known to the adolescent offender, and particularly high rates of incest abuse have been recorded (e.g., 30–46% in cited studies). The authors note that three groups of adolescent sex offenders are presented: sexually assaultive juveniles, pedophilic juveniles with victims three or more years younger than them, and a mixed group who has committed more than one class of offense. Across the literature, there is a consistent finding that juveniles with illegal sexual behavior problems are likely to have experienced prior sexual victimization, with estimates ranging from 40% in a national sample of adolescents, to 49% in a study with a very young sample, to 50–80% in other studies. However, the developmental pathways connecting prior sexual victimization and illegal sexual behavior problems in adolescence are unclear (e.g., whether it is reactive, conditioned, or learned behavior). Trauma and sexual abuse histories in offenders has long been of interest. Dillard and Beaujolais (2019) report on a review of 13 studies and note that only 4 reported higher rates of CSA and 3 reported multiple forms of trauma or abuse. Grabell and Knight (2009), in an interesting study, examined the age at which adolescent offenders were abused themselves and the development of sexual fantasies. Results indicate that abuse during the period 3–7 years of age was the only age that predicted sexual fantasy. The authors do not speculate why this would be so but it alerts us to the clear finding of much of the research, which is that there is more we do not know. Knight and Sims-Knight (2004) evaluated an etiological model in 218 juvenile offenders in inpatient sexual offender treatment programs and found support for their three-part model of etiology in which sexual drive/preoccupation, antisocial behavior, and callousness/unemotionality are critical factors. Simons et al. (2008) compared developmental experiences of child sexual abusers (n ¼ 132) and rapists (n ¼ 137) (total N ¼ 269) in a convenience sample of 280 incarcerated adult male sexual offenders in Colorado prisons identified through official records and obtained between 2003 and 2004. Differences were found in the etiology of sexual offending against children versus adults, with more sexuality in development found among child sexual abusers and more violence found in development among rapists. Compared to rapists, child sexual abusers were more likely to report incestuous sexual abuse, abuse by a male, multiple abuse episodes, and more severe abuse (involving force or oral or anal penetration). Developmental experience characteristics of child sexual abusers include significantly higher rates of child sexual abuse compared to rapists (73% vs. 43%) of which 55% was fondling and 15% was severe CSA (e.g., anal penetration). One third of abusers were sexually abused by more than one perpetrator, 54% were abused by a male, and 22% were abused by a family member. Compared to rapists, child sexual abusers were significantly less likely to have experienced childhood physical abuse (56% vs. 68%), emotional abuse, or

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witnessed parental violence. Compared to rapists, child sexual abusers were significantly more likely to have been exposed to pornography before the age of 10, reported masturbating before the age of 11 (8% vs. 60%,), reported more bestiality in childhood (11% vs. 38%,), and have anxious attachment style (rapists were more likely to have an avoidant attachment). Much of the research in this area has employed samples of incarcerated or adjudicated juveniles and adults. It is completely understandable that potential subjects who engage in behaviors which place them at considerable risk would be difficult to recruit for research, especially in light of mandated reporting of child abuse. Subjects identified by courts and found to suffer from the problem of interest to investigators (sexual offending) are readily identifiable. Considerable quality research has been conducted with these samples. Nonetheless there may be currently unknown differences between known offender samples and those who remain unknown. One could argue that offenders identified by law enforcement and handled by courts are the unsuccessful ones, and there may be many differences between that group and the group of unknown offenders. In this regard the work of Ybarra and Thompson (2018) is quite interesting. Using a national online survey in 2006 and 2012, 1,586 youth responded. More than one in six females and one in five males report engaging in some form of sexual violence before age 21. Sexual harassment was the most common form (23% of males and 17% of females), but actual sexual assault was reported by 10% of males and 12% of females. Older age was associated with higher levels of sexual assault. Five percent of non-perpetrators of rape reported to have been previously a victim of rape versus 37% of rape perpetrators. While volunteers to an online survey may be different from those who do not volunteer, nonetheless efforts to obtain samples of interest that are not yet identified in the community would be of incredible value in expanding knowledge about CSA. There has also been interest in whether online offenders are different from other sexual offenders. Babchishin et al. (2011) reviewed 27 studies. Online offenders were defined as those arrested or convicted, although one study employed self-report to define an online offender. Acknowledging the small sample sizes and preliminary nature of the data, the authors report that online offenders tended to be Caucasian and younger. They were twice as likely to be unemployed as the general population. Samples were mixed and included different types of sexual offenders. (See also Seto et al. 2011 and Babchishin et al. 2015.) Recidivism has received considerable attention. In a society that favors legal handling of behavior, it is not surprising that the impact of incarceration would be an interest. For example, Hanson and Morton-Bourgon (2005) summarized 82 studies of recidivism indicating that defiant sexual preferences and antisocial orientation were the major predictors of recidivism. (See also Hanson and Bussiere 1998.) Notwithstanding what has been an impressive body of research on various aspects of sexual offending, there is much yet to learn. Although there have been impressive efforts to conceptualize etiology (see, e.g., Marshall and Barbaree 1990; Ward and Siegert 2002), little research has elaborated on these conceptual models. A more complete understanding of the role of early life experiences, the family and

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larger social context, exposure to pornography, personality characteristics and cooccurring psychopathology, and other factors is important in understanding how sex offenders come to be. Research is needed which identifies components of illegal sexual behavior problems in youth, sexual offending in adults, and the identification of different types of sexual offenders defined at least in part by those components (e.g., sexual arousal, anger/hostility, reenactment of prior trauma) that are associated with CSA and can be targets of prevention and treatment efforts. The identification, recruitment, and study of people of all ages in the general population who engaged in CSA and who have not been identified by law enforcement or social services seems to be a critical need. Putting aside briefly the issue that children are abused in the making of child pornography, are there users of child porn who never abuse an actual child? Are the adverse effects of child pornography viewing more negative for some viewers than others (e.g., viewers with prior histories of abuse or violence)? True prevention is going to require substantial additional research on the nature and origins of CSA offending.

Effects of Sexual Abuse There is simply no question that knowledge about the harmful impact of sexual assault has expanded greatly since the late 1890s when Freud first suggested that sexual use of children was associated with mental health problems in adults. Early investigations including those of Freud are essentially observations, typically of patients. Beginning in the more modern period effects were described based on more rigorous clinical assessments of symptoms and standardized measures (see, e.g., Gomes-Schwartz et al. 1990). Over time different measures of harm or damage have been used in different studies. Many studies are based on clinical samples such as victims who are seen at emergency rooms or in mental health service organizations. Such studies raise questions about how similar these victims are to those who have not disclosed or who are in the community. Studies often group victims abused by a wide range of offenders including strangers, relatives, romantic partners, and the like. Many studies are cross-sectional, examining victims at one point in time, and do not follow the victim over extended periods of time after the assault to see how the harms and damages may change over time. Few studies have examined individuals before they were victimized and then after. Collaborations between CSA researchers and researchers in other areas may identify longitudinal samples which could address this issue. Most studies examine victims at one point in time and not over extended periods of time. Harms seen or not seen at one point in a lifetime may differ, disappear, or appear for the first time at some later point over a lifetime. Some types of damage may well not appear until years after the assault. For example, assaulted young children may not present with sexual performance problems until later in their development as older teenagers or as adults when sexual behavior is a normal part of life. There have been a precious few but important studies which have drawn random samples from the general community and compared victims and nonvictims.

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There is a large body of individual research reports over many decades which have been periodically reviewed. Most of this research consists of clinical studies in which a specific population (e.g., victims in treatment, sex workers, or people with substance abuse issues) is studied. There is always a question about how this special clinical sample may reflect the general community. Nonetheless, over a large body of research, a range of harms and damages has been identified with sexual assault. Research has examined the effects of abuse on children while still children. In a 1993 review, Kendall-Tackett et al. (1993) reviewed studies on the effects of childhood sexual abuse (abuse before age 18). Results of their review suggest that sexually abused children have more significant problems than children who are not sexually abused in nonclinical studies and in most studies comparing clinical samples of abused and non-abused children (but in a clinical sample for some reason other than abuse). A number of studies have found that, among clinical samples, abused and non-abused children do not show different symptoms, pointing to what is generally known which is that CSA is not the only factor causing children to have problems. As noted by the authors, CSA was associated strongly with sexualized behavior and more general problematic behavior (e.g., depression, aggression) but in the case of the latter symptoms not more than other children in clinical samples. Across studies generally 20% to 30% of victims exhibited a particular symptom except for PTSD, which most victims exhibited. Also noted by the authors, certain symptoms appear to be more consistent within age groups than across ages. The most common symptoms for preschoolers, for example, were anxiety, nightmares, general PTSD, internalizing, externalizing, and inappropriate sexual behavior. For school-age children, the most common symptoms were fear, neurotic and general mental health behaviors, aggression, nightmares, school problems, hyperactivity, and regressive behavior. For adolescents the most common symptoms were depression, withdrawal, suicidal or self-injurious behavior, somatic complaints, illegal acts, running away, and substance abuse. Nightmares, depression, withdrawn behavior, neurotic mental illness, aggression, and regressive behavior were most common across age groups. The authors note that previous studies have reported that between 21% and 49% of children thought to have been abused are asymptomatic at the time they were examined for the research. An early work by Conte and Schuerman (1987) reports on a study of 369 sexually abused children 4 to 17 years of age and a community comparison sample. Parentand social worker-completed behavior checklists of frequently reported symptoms of CSA were employed. The social worker-completed checklist of symptoms (e.g., low self-esteem, fearful abuse stimuli, generalized fear, academic problems) indicated that the average number of symptoms was 3.5. Twenty-seven percent of abused children had four or more symptoms. Differences between abused and non-abused children on a measure created out of parent data all indicated significant differences on all the dimensions of behavior. However, the effects of CSA are primarily an adult problem. A 1992 review by Beitchman et al. (1992) summarized a large body of research available by the early 1990s. Their review noted CSA to be associated with adult symptomatology, including sexual disturbances, anxiety, fear and depression, suicide, and re-

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victimization. Polusny and Follette (1995) reported on a review of published research available to them. Studies reviewed employed a wide range of methodologies including differing samples and measures. As reported by the authors, studies of nonclinical student samples point to CSA being associated with general psychological distress including various symptoms and psychiatric diagnoses. Studies report CSA associated with depression although rates range from 4% to 66% for non-abused and 13% to 88% for abused subjects. Differing methodologies may account for the large range. Studies also report CSA to be associated with self-harm behaviors including suicidal behaviors and self-mutilation. Anxiety, substance abuse, eating disorders, dissociation and memory impairment, somatization, and personality disorders are also reportedly associated with CSA. The authors also reviewed research pertaining to social and interpersonal functioning. As noted by the authors, studies point to increased hostility, fear, and distrust of others in CSA survivors. Research has pointed to problems in sexual satisfaction and sexual functioning in CSA survivors. High-risk sexual behaviors (e.g., a high number of sexual partners or unprotected sex) and re-victimization are also noted. Neumann et al. (1996) completed a meta-analysis of research published between 1974 and July 1992. Thirtyeight studies met stringent requirements for inclusion in the review including a clinically equivalent comparison group to the CSA group. Outcomes included those of affect (anger, anxiety, depression), behavior (re-victimization, self-mutilation, sexual problems, substance use, and suicidality), identity/relational (self-concept impairment and interpersonal problems), and psychiatric (dissociation, obsessions, compulsions, somatization, and traumatic stress responses). Results indicate CSA had a significant impact of psychological distress and dysfunction in adult women. Paolucci et al. (2001), in a more recent review, reviewed studies from 1981 to 1995. Thirty-seven studies met their stringent criteria for inclusion in the metaanalysis. Six major abuse effects were examined: PTSD, depression, suicide, sexual promiscuity, victim-perpetrator cycle, and poor academic achievement. These 37 studies included 88 samples comprising 25,367 subjects, of which 36% reported childhood sexual abuse. This major review employed an effect size analysis in which a positive effect indicates that CSA had a negative impact on functioning and a negative effect size indicated that CSA had a positive consequence to the examined outcomes. The results of this recent meta-analysis indicate that a substantial effect of childhood sexual abuse was found for PTSD, depression, suicide, sexual promiscuity, and academic achievement. The largest effect sizes were for suicide (0.44), depression (0.44), and PTSD (0.40). Studies of the general population, especially those based on random samples of subjects, are extremely important. Factors that may account for variation in functioning and are not measured or are unknown are assumed to be in similar proportions in the victim and non-victim samples due to random selection. Subjects are also not selected for some specific factors such as abuse status or mental health condition and thus findings may be more relevant to understanding impact of assault in the general population.

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Burnam et al. (1988) report on a large cross-sectional probability study of 3,132 households in two Los Angeles communities and compared lifetime diagnoses of nine major mental disorders in those who reported and did not report sexual assault. Just over 13% (13.2%) of the households reported lifetime sexual assault (i.e., a sexual assault at some point over a lifetime). One third of sexual assault victims reported one lifetime assault; two thirds reported two or more. Lifetime assaults were more common in women (16.7%) than in men (9.4%) and in non-Hispanic White women (19.9%) than Hispanics (8.1%). Eighty percent of assaulted individuals were assaulted between ages 16 and 20. Assaulted individuals were more likely to exhibit major depressive disorder, drug abuse or dependence, panic disorder, and obsessive compulsive disorder. Of note, the rate of onset for non-assaulted individuals is relatively constant, while for assaulted individuals, the onset is higher within the year after the assault. A 1992 study (Saunders et al. 1992) reported on a representative probability sample of adult women in Charleston County, South Carolina. Of 391 respondents, 33.5% had been the victim of at least one assault before age 18. Over 24% (24.6%) of victims experienced a physical contact assault (rape or molestation), of which 15.6% reported molestation, 10% suffered a child rape, and 12% a non-contact assault. Typically, victims reported significantly more mental health problems than non-victims, including depression, agoraphobia, obsessive compulsive disorder, social phobia, simple phobia, sexual disorders, post-traumatic stress, and suicide attempts. Golding (1996) examined the functional impact of a sexual assault history in two general population surveys (N ¼ 6,024) in Los Angeles and North Carolina as part of the Epidemiological Catchment Area study. Results indicate that bed days and restricted activity days were significantly more common for persons with a history of sexual assault than those without. The odds of restrictions in normal activities were one and one-half times greater for those with a history of sexual assault. Repeated assaults, assaults by a spouse, and assaults associated with sexual disturbances were more strongly associated with functional impairment. A 1999 study (Fleming et al. 1999) of 3,958 female Australians selected from the compulsory voting roles found that 41% reported at least one sexual experience before age 16 and 20% reported CSA. Long-term effects were attributed to CSA by women (46%) which included low self-esteem (28%), distrust (25%), sexual problems (27%), fear of men (9%), depression (9%), eating problems (7%), drug problems and alcohol problems (1% each), and other problems (4%). Women reporting more severe forms of sexual abuse were more likely to experience longterm negative effects. Multivariate analysis indicated that other than women with a history of penetration, the association between sexual abuse and mental health problems did not remain significant when controlling for social and family background variables. The authors note, “The results of this study along with other research indicate that the associations between CSA and adult difficulties persist even after the potentially confounding childhood family and social factors are controlled for. . .CSA coupled with growing up in a family characterized by

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domestic violence, alcohol abuse, and emotional deprivation increases the likelihood of long-term negative outcomes” (p. 156). A US study (Saunders et al. 1999) was designed to learn the prevalence of a history of completed rape in childhood among American women to collect incidentcharacteristic data and to examine the increased risk, if any, of childhood victimization for certain mental health problems. Telephone interviews were conducted with a national probability sample of women using a multistate, stratified, random-digit dialing method. One sample oversampled for younger women (18–34) based on the idea that younger women may be at higher risk for sexual assault. The average age for first child rape was 10.8 years and the mode was 16. The majority of first rapes (59.8%) occurred prior to age 13. The most common offender was a nonrelative known to the victim (38.9%). Strangers were the offender in 11.2% of cases. Child victims were more likely than non-victims to report both lifetime and current PTSD (victims three times as likely as non-victims) and depression (victims nearly two times as likely as non-victims). At the time of the interview, child rape victims were three times more likely than non-victims to suffer from depression. Victims were also more likely to have taken prescriptions in a non-prescribed manner, to have used illicit drugs, and to report current and lifetime alcohol abuse. Thompson et al. (2002) report on data from the National Violence Against Women Survey, a national telephone survey about women’s experience with violence. Over 8,000 women provided responses. Seven measures of health problems in adulthood, including perception of general health, serious physical injury, miscarriage or stillbirth, chronic physical health condition, chronic mental health condition, drug use, and alcohol use were studied. Both physical and sexual abuse were associated with five of seven health outcomes. Women who were sexually abused in their youth (age 18 or under) reported poor perceptions of general health, sustained a serious injury in adulthood, have had a miscarriage or stillbirth, acquired a chronic mental health condition in adulthood, and have used drugs in the month before the interview. A more recent British study reports on a representative sample of men and women in the UK (Plant et al. 2005). Subjects were asked to indicate during the previous 12 months if any of eight possible behaviors had “interfered with daily life.” Of the sample, 12.5% of females and 11.7% of males reported having been sexually abused. As can be seen, the differences between abused and non-abused individuals’ experiences with problems in the previous 12 months are small but several are significant. For example, for women, eating problems were associated with sexual abuse at any age. When the authors combined all problems, sexual abuse before the age of 16 was associated with having at least one problem behavior. Thirty six percent of abused versus 20.7% of non-abused adults had at least one problem behavior. For both genders, being abused after age 16 was associated with self-report of poorer physical health than non-abused adults. Adults who were abused reported poorer mental health than those who were not. Finally Elliott et al. (2004) report on a general population study of 941 individuals. Results indicate that adults assaulted in adulthood were more symptomatic on all ten scales of the Trauma Symptom Inventory (TSI) than non-assaulted peers.

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Assaulted men were more symptomatic than women on Dysfunctional Sexual Behavior and Sexual Concerns. Women were more symptomatic on Tension Reduction Behavior than men. Younger subjects were more symptomatic than older subjects. Men were angrier than women assaulted in adulthood. CSA was higher in ASA (Adult Sexual Assault) than non-assaulted subjects (59% vs. 18%). A significant body of research points to fact that CSA is associated with significant long-term negative effects. No single negative effect is seen in all victims nor is it clear when in adulthood negative effects (a.k.a. symptoms, problems, harms, and psychological damages) will appear. Many victims suffer some effects not understanding that their symptoms are associated with CSA. Other victims hide symptoms from others as long as possible or deny that the behavior is a problem (e.g., substance abuse or compulsive sexuality). CSA is a negative experience. How victims react may depend on a range of risk and resiliency factors. It is unlikely that a single theory will explain the wide range of behaviors that may result from CSA. Freeman and Morris (2001) provide a nice review of conceptual models explaining CSA effects. Although not all the frameworks are really complete explanations of the adverse effects of CSA (e.g., child abuse accommodation syndrome), the authors do point out that different effects may result from different mechanisms. Some behaviors (effects) may be the result of learning (e. g., cognitions that the world is unsafe or that the victim’s only use is as a sexual object). Other effects such as anxiety, hyperarousal, fears, and others are related to responses to overwhelming trauma. Emotional problems including depression or anger may be reactions to CSA. Difficulties in relationships, including distrust, negative attachment, or attraction to harmful partners, are more a function of disrupted or warped development which takes place when a child is sexually abused. The point is to avoid a simplistic formulation which tries to account for all the effects and harms resulting from CSA by a single theoretical or conceptual framework. As noted, how people react to the experience of CSA can be quite varied.

Key Points • Reports suggest that child sexual abuse in the United States has declined over the past 30 years, but it remains common. Different definitions and methodological issues persist that contribute to varying estimates of incidence and prevalence. • The vast majority of sexual abuse against youth is perpetrated by someone the child knows, such as an acquaintance or family member. More than one-third of all sexual offenses against youth are committed by other youth. • Various factors at the family and child levels may increase children’s risk of abuse, including a child’s disability or LGBTQ status. Research on possible differential risk associated with a child’s race and ethnicity is lacking and needed. • The long-term effects and harms of child sexual abuse vary from person to person but may include behavioral responses to trauma, emotional problems, and difficulties in relationships. A simplistic explanation that seeks to account for all of its effects should be avoided.

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Summary and Conclusion As noted above this chapter could not deal with all aspects of CSA. The material above does reflect current basic knowledge about many aspects of CSA, and we encourage the reader to appreciate that learning about CSA is likely to be a lifelong process as research explores new facets of the problem and broadens understanding. Important in the near future will be increased efforts to develop definitions and categories of abuse which help distinguish between more subtle forms of sexual interactions (e.g., entering the bathroom while a child is bathing), examine acts and motivations for the acts, and identify other dimensions which lead more directly to interventions. Some attention should be given to developing taxonomies of acts in offenders (i.e., abusive behaviors), motivations for those acts, and victim responses.

Cross-References ▶ Child Sexual Abuse Disclosure and Forensic Practice

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Paolucci, E. O., Genuis, M. L., & Violato, C. (2001). A meta-analysis of the published research on the effects of child sexual abuse. The Journal of Psychology, 135(1), 17–36. Pereda, N., Guilera, G., Forns, M., & Gómez-Benito, J. (2009). The prevalence of child sexual abuse in community and student samples: A meta-analysis. Clinical Psychology Review, 29(4), 328–338. Pérez-Fuentes, G., Olfson, M., Villegas, L., Morcillo, C., Wang, S., & Blanco, C. (2013). Prevalence and correlates of child sexual abuse: A national study. Comprehensive Psychiatry, 54(1), 16. Peters, S. D., Wyatt, G. E., & Finkelhor, D. (1986). Prevalence. In D. Finkelhor & S. Araji (Eds.), A source book on child sexual abuse (pp. 15–89). Thousand Oaks: Sage. Plant, M., Plant, M., & Miller, P. (2005). Childhood and adult sexual abuse: Relationships with ‘addictive’ or ‘problem’ behaviours and health. Journal of Addictive Diseases, 24(1), 25–38. Polusny, M. A., & Follette, V. M. (1995). Long-term correlates of child sexual abuse: Theory and review of the empirical literature. Applied and Preventive Psychology, 4(3), 143–166. Prevoo, M. J., Stoltenborgh, M., Alink, L. R., Bakermans-Kranenburg, M. J., & van IJzendoorn, M. H. (2017). Methodological moderators in prevalence studies on child maltreatment: Review of a series of meta-analyses. Child Abuse Review, 26(2), 141–157. Roberts, A. L., Rosario, M., Corliss, H. L., Koenen, K. C., & Austin, S. B. (2012). Childhood gender nonconformity: A risk indicator for childhood abuse and posttraumatic stress in youth. Pediatrics, 129(3), 410–417. Roosa, M. W., Reyes, L., Reinholtz, C., & Angelini, P. J. (1998). Measurement of women's child sexual abuse experiences: An empirical demonstration of the impact of choice of measure on estimates of incidence rates and of relationships with pathology. Journal of Sex Research, 35(3), 225–233. Rothman, E. F., Exner, D., & Baughman, A. L. (2011). The prevalence of sexual assault against people who identify as gay, lesbian, or bisexual in the United States: A systematic review. Trauma, Violence, & Abuse, 12(2), 55–66. Saunders, B. E., Villeponteaux, L. A., Lipovsky, J. A., Kilpatrick, D. G., & Veronen, L. J. (1992). Child sexual assault as a risk factor for mental disorders among women: A community survey. Journal of Interpersonal Violence, 7(2), 189–204. Saunders, B., Kilpatrick, D., Hanson, R., Resnick, H., & Walker, M. (1999). Prevalence, case characteristics, and long-term psychological correlates of child rape among women: A national survey. Child Maltreatment, 4(3), 187–200. Seto, M. C., & Lalumière, M. L. (2010). What is so special about male adolescent sexual offending? A review and test of explanations through meta-analysis. Psychological Bulletin, 136(4), 526. Seto, M. C., Hanson, R. K., & Babchishin, K. M. (2011). Contact sexual offending by men with online sexual offenses. Sexual Abuse, 23(1), 124–145. Seto, M. C., Babchishin, K. M., Pullman, L. E., & McPhail, I. V. (2015). The puzzle of intrafamilial child sexual abuse: A meta-analysis comparing intrafamilial and extrafamilial offenders with child victims. Clinical Psychology Review, 39, 42–57. Silovsky, J. (April 30, 2020). Personal communication by email with J.R. Conte. Simons, D. A., Wurtele, S. K., & Durham, R. L. (2008). Developmental experiences of child sexual abusers and rapists. Child Abuse & Neglect, 32(5), 549–560. Sullivan, P. M., & Knutson, J. F. (2000). Maltreatment and disabilities: A population- based epidemiological study. Child Abuse & Neglect, 24(10), 1257–1273. Thompson, M. P., Arias, I., Basile, K. C., & Desai, S. (2002). The association between childhood physical and sexual victimization and health problems in adulthood in a nationally representative sample of women. Journal of Interpersonal Violence, 17(10), 1115–1129. Tracy, N. (2019, July 26). What is child sexual abuse?, HealthyPlace. Retrieved on 2019, September 29 from https://www.healthyplace.com/abuse/child-sexual-abuse/what-is-child-sexual-abuse. Veneziano, C., & Veneziano, L. (2002). Adolescent sex offenders: A review of the literature. Trauma, Violence, & Abuse, 3(4), 247–260. Ward, T., & Siegert, R. J. (2002). Toward a comprehensive theory of child sexual abuse: A theory knitting perspective. Psychology, Crime and Law, 8(4), 319–351.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Disclosure of Child Sexual Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Forensic Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Arguably the process whereby children come to disclose that they are being or have been sexually abused is the first step in professionals responding to sexual abuse. There is agreement that disclosure is a process rather than an event and that most children do not disclose until adulthood. Disclosure leads to forensic and clinical interest in false reports, suggestibility, and criteria which help adults confirm a child’s disclosure of abuse. Keywords

Child Sexual Abuse · Disclosure · Abuse Criteria · Suggestibility · Assessment Protocols

This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. J. R. Conte (*) · J. Simon Joshua Center on Child Sexual Abuse, University of Washington, Seattle, WA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_333

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Introduction Since the early days of modern interest in child sexual abuse (see ▶ Chap. 30, “Sexual Abuse of Children”), child and adult victims’ disclosures of their childhood sexual abuse have been met with skepticism by many. There was a suspicion, especially of young children, that their memoires could not be accurate – that adults who often had positions of authority and power (e.g., teachers, priests, middle-class fathers, etc.) could not possibly do what the survivors said was done to them. There was also an appreciation that some styles of interviewing or assessment might lead children to report what did not take place. Many adults did not understand young children’s reports of abuse, while others believed that phallic images in children’s art were a disguised disclosure of sexual abuse. In this context of doubt, denial, and faulty theories, there was a significant increase in efforts to understand how children disclose, how they could be helped to make disclosures, and how adults could have confidence in the veracity of those disclosures. Hence, forensic practice to evaluate disclosures and possible experiences of abuse became a key area in the development of professional practice and knowledge within the field. This chapter addresses the existing research on both disclosures of child sexual abuse and the forensic responses that may consequently follow.

Disclosure of Child Sexual Abuse Arguably the disclosure of CSA is a vital if not the most vital step in responding to abuse. Without knowing that a child has been abused, nothing for that child can be accomplished. As illustrated below this may well be a major reason for considerable attention being devoted by researchers and professionals to the topic. Disclosure is the child’s report or confirmation that they have had an experience. While there are differences in how various professionals have conceptualized disclosure, there is a rather amazing level of agreement about many things. It is generally understood that disclosure is a process and not an event (Alaggia et al. 2019; Sorensen and Snow 1991). Children may disclose information about negative experiences in a piecemeal fashion, perhaps to test the responses of others to what they have to say. Children who have had multiple abuse experiences may disclose aspects of one abuse event and then later provide information about other events. Children locked in abusive situations with offenders who have gone to great lengths to convince them that they will not be believed or that they will get in trouble or have been threatened with some dire consequence may be reluctant to disclose. Children who have been successfully conditioned to believe that they gave consent or wanted the abuse may also fear disclosure. Little is understood about why children disclose when they do. Some children behave in ways that alert adults that something may be going on. Behavior change or certain behaviors (e.g., developmentally inappropriate sexual knowledge, deterioration in behavior) may indicate that the child is under some kind of stress. While it is incorrect to believe that such behaviors or change in behaviors always indicates

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abuse, it is important to recognize it as indicating that the child should be talked to. So-called indirect disclosure through a child’s behavior, contrary to what some have argued, is not really a disclosure, but is an important alert to adults to inquire further with the child. Indeed, the first step in identifying a child as a possible victim is the attitude and knowledge of adults with whom the child comes in contact. Changes in behavior, behavior indicative of stress or emotional concerns (e.g., nightmares, reluctance to be with certain people or go to certain places, depression, aggression), should all cause the adult to wonder what may be going on with the child. Some children disclose directly when asked or do so on their own. This is generally thought of as a direct disclosure. Parents or other adults may inquire about the child’s experiences beginning with general questions (e.g., How was youth group today? How was your time at your friend Billy’s house?) and becoming more specific when the child’s response requires a follow-up (e.g., Child: “I don’t want to go there anymore.” Adult: “Did something happen?”) and becoming more specific (e.g., Child: “I got hurt.” Adult: “Who hurt you?” and, if appropriate, Adult: “What part of your body was hurt?”). The often-cited report by Sorensen and Snow (1991) examined the disclosure process of 116 children (3–17 years of age) and, importantly, confirmed the abuse by confession or plea (90%), conviction in criminal court (14%), or medical evidence (6%), and report a number of findings related to accidental andpurposfeul disclosure, most of which have borne out in more recent research. Accidental disclosure (i.e., discovery) of the abuse took place in 74% of cases more often in preschool children versus adolescents who disclosed purposively. Accidental disclosure was related to exposure to the perpetrator (amount of time child spent with offender), inappropriate or excessive sexual behavior, inappropriate statements (e.g., “Suck on my pee pee, Mommy”), or shared confidence with a friend who did not keep the confidence. Alaggia (2004) suggests that disclosures may be thought of as accidental, purposeful, or prompted/elicited. There is general agreement that most CSA is not disclosed until adulthood. In a 2008 review, London, Bruck, Wright, and Ceci report that estimates range from 55% to 69% of child victims who do not disclose until adulthood. Hébert, Tourigny, Cyr, McDuff, and Joly (2009) report on a telephone study of 804 adults in Quebec with a prevalence rate of 22% women and 9.7% men abused in childhood with 21% of child victims reporting within a month of the abuse and 48.8% waiting 5 years or more to disclosure. Prompt disclosure was 3.76 times more likely among females and 6.76 times more likely for victims abused by non-family members than family members. In a sample of 487 male survivors, the average delay in disclosure was 28 years, and the age at first disclosure was 32. Twenty-seven percent first disclosed to a partner or spouse and 20% to a mental health professional. Alaggia (2005), based on 30 interviews with adult survivors, reports 58% did not disclose until adulthood. More recently, based on a qualitative study of 40 adult survivors, Alaggia (2010) identifies a number of factors which may be associated with delay in disclosure, including individual characteristics of the victim (e.g., developmental factors or temperament or personality factors), family dynamics (rigidly fixed gender

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roles with dominating fathers, presence of another form of child abuse, insensitive responses to disclosure), neighborhood and community (e.g., social isolation, teachers not knowing how to respond), and cultural and societal attitudes (e.g., sexualization of young girls [viewing them as seductive], or attitudes that men could not be victims). While these are not all empirically identified, they provide an excellent conceptual overview for the range of factors that well could impact disclosure. Many barriers to disclosure have been identified. In an early review, Ullman (2002) reports a critical review of literature on social reactions to disclosure which yielded 9 nonclinical/convenience samples and 23 clinical samples. Studies showed a broad range of negative reactions to both child and adult disclosures of CSA (e.g., disbelief, blame, minimization, ignoring the disclosure, egocentric responses, accusing victim of lying, punishing or beating the victim, parental rejection, neglect, indifference, anger, and avoiding talking or listening). Negative reactions to CSA disclosure were associated with significant harmful effects on various measures of psychosocial adjustment in these studies (i.e., more psychological symptoms, psychopathology, self-denigration, dissociation, and borderline symptoms). Conversely, positive reactions (especially maternal support) are associated with better adjustment as children, but not necessarily as adults. In a recent review of 33 articles with more than 42,000 participants (Alaggia et al. 2019), delayed disclosure was found to occur in high rates. For example, one study of 1,737 CSA cases found disclosure was delayed by 72 h to 1 month in 31% of cases and by more than a month in 22% of cases. In a nationally representative telephone study that identified 288 female survivors of child rape, 27% of these women reported disclosing within a month, while 58% did not disclose for between 1 and 5 years; moreover, 28% reported having never told anyone until being asked during the study interview. Another study of 487 men found an average delay of more than 20 years for first disclosure. Barriers (and facilitators) to disclosure included intrapersonal, interpersonal, and contextual factors. Age and gender strongly predicted delayed or withheld disclosure with fewer disclosures occurring among younger children and boys. Other reviews have focused on different barriers. For example, McElvaney (2015) found reasons for patterns of delay include (a) younger age, (b) abused by family member, (c) whether there is a supportive parent or not, (d) the fear of upsetting parent or other consequences, (e) being a boy, (f) mental health difficulties, and (e) the fear of not being believed. High rates of nondisclosure also occur in forensic settings even when corroborative evidence exists that abuse has occurred (e.g., medical evidence, witness reports, or abuser’s confession). Disclosure strategies among young people include more direct (seeking peer support, seeking non-professional adult support, disclosing to service provider) and less direct strategies (risk-taking behaviors, not talking about abuse). Morrison, Bruce, and Wilson (2018) report on a systematic literature review of barriers and facilitators to childhood disclosure of CSA based on seven studies published between 1996 and 2012. Six themes were identified as barriers and facilitators to disclosure: (1) a fear of what will happen if they disclose, (2) fearing being disbelieved by others if they disclose, (3) the emotional impact of the abuse

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(e.g., shame, embarrassment, guilt, etc.), (4) having the opportunity to disclose (e.g., the place or time, or a safe, private, familiar setting), (5) concern for self and others (e.g., wanting to discourage future abuse or not get family members in trouble), and (6) feelings toward the abuser (mixed feelings versus fear or terror toward them). Tener and Murphy (2015) reviewed studies published between 1980 and 2013 on disclosure of CSA during adulthood and yielded 28 studies meeting inclusion criteria. The study found that adult disclosure is described in the literature as a deliberate, intentional, purposeful, and thoughtful decision. The process of telling among adults is less understood but seems to consist of preparing, telling, revising, and sharing. Barriers to disclosure among adults include intrapersonal (not understanding what happened to them was abuse or doubting memory, shame, embarrassment, etc.), interpersonal (fear of others’ reactions, not being believed), and sociocultural factors (role of males, negative attitudes toward survivors). Facilitators for disclosure among adults include (a) a desire to protect others, (b) a trusting social relationship, (c) social supports in adulthood, and (d) media stories and legal cases that receive popular attention. A number of studies of disclosure have taken place with children seen in forensic settings. Anderson (2016) examined 196 forensic interviews at a Children’s Advocacy Center and reported that two-thirds of children interviewed disclosed “actively” versus one-third who made a “tentative” disclosure. A tentative disclosure was defined as somewhere in between a disclosure and non-disclosure. Children were more likely to disclose “tentatively” if they were older, were multiracial or biracial (versus Caucasian), had an unsupportive family, or if the abuse was witnessed or was reported after a perpetrator confession, or the alleged perpetrator was an adult (versus a peer) or unrelated (versus a relative). These results are somewhat surprising given prior research indicating children abused by family members were more reluctant to report. Lowe, Pavkov, Casanova, and Wetchler (2005), in a study of a diverse sample of undergraduates, report factors that inhibited disclosure were shame associated with abuse, fear of not being believed, fear of being removed from the caretaker’s home, and fear that disclosure would impact the relationship with a parent and break up the family. Fontes and Plummer (2010), based on a review of published literature, identified a series of cultural factors which may impact disclosure. These are (a) shame; (b) taboos and modesty; (c) virginity; (d) sexual scripts; (e) the status of females; (f) “obligatory” violence; (g) honor, respect, and patriarchy; (f) religious values; (g) varied reporting costs; (h) structural barriers; and (i) cultural supports. In a 2003 report, Goodman-Brown, Edelstein, Goodman, Jones, and Gordon report on 213 child victims seen at a district attorney’s office. This is a noteworthy study in part because of the rigor of its methodology. Results note factors associated with delay in disclosure were age, type of abuse (intra-family vs non-family perpetrator), fear of negative consequences to others, and if the child perceived responsibility for the abuse. Analyses indicate that fear of negative consequences to others was more important for older rather than younger children. Older children were more likely to feel responsible for their own abuse.

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Schaeffer, Leventhal, and Asnes (2011) report on a study in which forensic interviewers asked children about how they came to tell about sexual abuse and if children waited to tell about abuse, and the children gave specific answers to these questions. The reasons children identified for why they chose to tell were classified into three domains: (1) disclosure as a result of internal stimuli (e.g., the child had nightmares), (2) disclosure facilitated by outside influences (e.g., the child was questioned), and (3) disclosure due to direct evidence of abuse (e.g., the child’s abuse was witnessed). The barriers to disclosure identified by the children were categorized into five groups: (1) threats made by the perpetrator (e.g., the child was told they would get in trouble told), (2) fears (e.g., the child was afraid something bad would happen), (3) lack of opportunity (e.g., the child felt the opportunity to disclose never presented), (4) lack of understanding (e.g., the child failed to recognize abusive behavior as unacceptable), and (5) relationship with the perpetrator (e.g., the child thought the perpetrator was a friend). As in all research, it is important to consider the sample employed in the study. For example, Azzopardi, Eirich, Rash, MacDonald, and Madigan (2019) conducted a meta-analysis of cases in forensic settings. This meta-analysis on the prevalence of child sexual abuse disclosure yielded 216 studies with 45 samples (n ¼ 31,225). The review notes there is widespread evidence that non-disclosure and delayed disclosure of CSA are common in childhood: among children under 18, the mean prevalence of CSA disclosure in forensic settings was found to be 64.1%. Therefore, more than one-third of youth do not disclose when interviewed. Variability in prevalence estimates between studies was attributed to (a) child age and gender (the most frequently and reliably measured predictors of disclosure in forensic settings), (b) whether there was prior disclosure, and (c) study year. The authors point out methodological issues in the research reviewed, including inconsistent operational definitions of terms such as abuse, the retrospective self-report of subjects, and lack of confirmation of the abuse. The latter point is not an insignificant one. Cases referred to a forensic setting are unlikely to consist of only true cases of abuse. So non-disclosure in some cases could be an accurate assessment resulting in the correct decision the child was abused but in other cases could mean that an abused child failed to disclose when in fact a disclosure would have been appropriate. As a result of this significant unknown regarding what non-disclosure means, it is difficult to know what disclosure rates in studies employing cases from forensic practice actually mean. Children typically disclose to their mothers and peers (Malloy et al. 2007). This has given rise to efforts (e.g., parent alienation syndrome) to blame mothers for encouraging false reports. Some have thought that disclosure to family or friends should be thought of as a “partial disclosure” since it is somehow thought that disclosure to professionals is more “believable.” Children disclosing and then recanting is a well- known event (see, e.g., Summit 1983; Malloy et al. 2007). The notion that the chaos resulting from disclosure would have an impact on children’s willingness to maintain a description of something that causes such upheaval should not be a surprise. Efforts to suggest that recantation is more valid

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than the original disclosure are unfounded in any research. Staller and NelsonGardell (2005) make the point that children delay, partially disclose, affirmatively (sometimes accidently) disclose, retract, and reaffirm as part of the process of disclosing. Malloy, Lyon, and Quas (2007) estimate that 23% recant in cases seen in a family court. Easton (2013) reported only 15.1% of allegations are first reported to professionals. McElvaney et al. (2014) point out, based on interviews with 22 youth, that nondisclosing is not a passive process but rather takes mental and emotional activity of the victim not to disclose. They refer to the process of disclosing as one starting with active withholding (of information), the pressure cooker effect (struggle between wanting to tell and not wanting others to know), and confiding the secret (sharing of deeply personal information). It is important to add that the active withholding phase is strengthened by efforts of the offender to induce a sense of responsibility for the victim’s own abuse, threats of dire consequences if disclosed, and bribes which create a false sense of duplicity in many victims. A complete understanding of the many pressures not to tell makes it somewhat surprising that victims ever tell and gives a window into how horrible the experience is for most victims. There is some confusion in thinking about disclosure as to whether it is something the victim does or something that results from an interaction between adults and a child. For example, Alaggia (2004) refers to behaviors often thought to be indicative of CSA (e.g., clinging, regression in behavior accomplishments, anger, nightmares) as indirect disclosure. (See also Ungar, Barter, McConnell, Tutty, and Fairholm (2009) who also address indirect disclosure strategies, including risk-taking behaviors such as self-harm.) These would seem to imply a conscious or unconscious effort to tell indirectly. Certainly behaviors which indicate stress or trauma should be identified and evaluated, but it does not seem to add much to regard them as a disclosure process unless one thinks of two general types of disclosure: one which describes how instances of sexual abuse are discovered by others and the process whereby victims come to report on their experience. In the first instance, knowing the offense history of an adult, observing an adult engaged in inappropriate behavior with a child, prior reports of abuse, and others are all part of the process whereby potential instances of CSA are identified. It is not that Alaggia (2004) or Ungar et al. (2009) are wrong but rather it seems more useful to think of disclosure by the child as one thing and due diligence by adults in identifying children who are being or are at risk for being abused as a different process. Supporting children to disclose can be difficult for many adults. On the one hand, most professionals and indeed most adults will say that getting children to come forward when being abused is a worthwhile undertaking. On the other hand, there is a reluctance among some adults to support disclosure because it means that the abuse has to be reported. Some professionals hold negative views of the consequences to child and family of reporting to child protective services or law enforcement. Some simply do not want the hassle that reporting involves. Asking children direct questions about experiences, including CSA, is not that complicated, although certainly understanding verbal communications from very

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young children can be a challenge. Asking a child about his/her experience is arguably the most direct way to identify children who are being abused (Lemaigre et al. 2017; see also McElvaney 2015). Ungar et al. (2009) note that CSA reports increased fourfold from 7% to 31% when clients were asked directly whether they had been molested. It is the ambivalence of many professionals and discomfort of some adults that prevent this obvious disclosure support from being more widely employed. There has been some interest in the effects of disclosure, although interestingly much of this is from several decades ago. This may be a function of a concern among many about child protection and law enforcement being involved with children and families. It is unfortunate that this interest has not continued into the current phase of dealing with CSA. McNulty and Wardle (1994) report on a review of research available to them and comment that the possible link between disclosure and psychiatric symptoms “has been noted so frequently that consideration of possible links seems important” (p. 550). One of their hypotheses is that disclosure is associated with an increase in symptoms because the release of submerged memories is associated with intense distress. The authors also point out the negative impact of reactions of others to the disclosure. In one study, Arata (1998) examined the effects of disclosure on 204 female survivors of CSA and reports that the disclosure was not related to current level of functioning but was associated with fewer intrusive images of the abuse and avoidant symptoms. Disclosure was less common with more severe levels of assault and when the victim was related to the perpetrator. Berliner and Conte (1995) report on a retrospective study of 82 children. Results indicate that although often thought to be traumatic, separation from family and testifying in court were not related to distress. Talking with a detective or prosecutor, a medical exam, expecting to testify, and having more contact with system professionals were related to distress. Henry (1997) reported on a study of 90 children (9 through 19 years of age). Results indicate that the number of interviews the child had was associated with scores on the Trauma Symptom Checklist for Children. There was no association with trauma scores for the 30 children who testified nor the 36 children who were removed from the home. More recently, Hershkowitz, Lanes, and Lamb (2007b) interviewed 30 children and their families. More than half (53%) of the children delayed disclosure for between 1 week and 2 years, fewer than half first disclosed to their parents, and over 40% did not disclose spontaneously but did so only after they were prompted; 50% of the children reported feeling afraid or ashamed of their parents’ responses, and their parents indeed tended to blame the children or act angrily. The disclosure process varied depending on the children’s ages (33% of 7–9-year-olds versus 73% of 10–12-year-olds), the severity (more severe and greater frequency of abuse meant more delay), the parents’ expected reactions (88% of children whose parents reported stress or being anxious delayed), the suspects’ identities (more familiar experienced longer delays), and the strategies they had used to foster secrecy. In terms of the effects of disclosure, 50% reported feeling generalized distress, and 50% reported feeling fear or shame of the parent. Factors positively associated with

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feelings of fear or shame included perpetrators were familiar (78%), abuse was serious (83%), abuse was repeated (79%), delay of disclosure (88%), disclosed to friends or siblings (79%), and did not spontaneously disclose (77%). Parent reactions to disclosure were judged to be supportive (37%) and unsupportive (63%). Factors positively associated with unsupportive parental reaction were perpetrators were familiar (89%), abuse was serious (92%), abuse was repeated (93%), parental response to stress is anxious (88%), delay of disclosure (81%), and child reported feelings of fear and shame (87%). It should be noted that after the investigation, 4 of 30 children claimed the abuse did not happen (retracted). Kogan (2005) examined the role of disclosure on adolescent symptomology in a national probability sample of adolescents. Participants’ mean age was 14.9, and the sample was 78% female, 62% White non-Hispanic, 15% African American, and 13% Hispanic. Delayed disclosure was associated with an increased number of clinical symptoms. Delayed disclosure was also associated with frequency of abuse and having a family relationship to the perpetrator. Prompt disclosure to an adult was associated with a reduced risk of revictimization. Penetration, fear, and delayed disclosure were significantly associated with the presence of symptoms, but interestingly neither fear nor penetration was associated with delay in disclosure. Finally, Jonzon and Lindblad (2004) evaluated abuse characteristics, disclosure, and social support in a sample of 122 adult survivors of CSA. Twenty-one categories of disclosure receivers were identified. Slightly less than one-third of survivors disclosed in childhood. The average delay in disclosure was 21 years. Those who disclosed in childhood reported more instances of physical abuse, multiple perpetrators, and the use of violence. Younger age at first event and use of violence best predicted delay. Interestingly, for those who told in childhood (N ¼ 26), 15 reported the abuse continued after disclosure. Mothers (N ¼ 18) were the most common receivers in childhood and therapists (N ¼ 33) most common in adulthood. Abuse of longer duration, the use of violence, and high number of perpetrators were associated with more negative reactions of others in childhood. As noted above, the critical role disclosure plays in all other responses to CSA calls for more research in this area. The decisions to protect children when necessary by removal from their homes and to prosecute offenders and indeed the many negative aspects of being a victim of CSA in general make it clear that the negative effects of disclosure are not going to go away. Studies of adults recalling childhood experiences are helpful, but examination of children’s experiences while still in childhood should provide greater insight into all aspects of disclosure. What brings a child to disclose in the first place? What are the obstacles as perceived by the child to disclosure? Are there means to increase disclosure earlier after the abuse first starts? Once disclosure takes place, what are the most difficult aspects of social, medical, legal, and mental health interventions? These and a host of other questions are among the most pressing. In particular, because the systems have changed over the decades, understanding based on the current population of children and the current approaches by various systems would be of great value.

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Forensic Practice Forensic literally means belonging to, used in, or suitable to courts. CSA involves a number of legal practices. The effects of CSA are a subject of frequent civil lawsuits in which victims sue the persons or organizations responsible for the sexual abuse. CSA is raised in some family law matters pertaining to child custody; often this involves allegations of abuse and counter allegations that the child’s disclosures are false or manipulated by the other family member. CSA is a violation of criminal laws in every state and most countries although, as noted above, there were discussions early in modern awareness of CSA about whether treatment or prosecution was the preferred way to handle cases, and this issue is still raised in cases of very young offenders. While child abuse professionals may hope that policy makers would be open to data and expert opinion about offenders and victims, it is abundantly clear that the law will continue to have a significant impact on CSA. This is hardly a new awareness, and it is this fact that has been largely responsible for a great deal of research on CSA and forensic issues. In addition to the role of law, there is a deep-seated mistrust of children in the minds of some adults. Children are viewed as intellectually and developmentally immature, so their memories and reports are regarded with suspicion. Some have argued that children are easily manipulated by adults, especially mothers who are out to harm former male partners. These may or may not be correct ideas, but they have been exploited and exaggerated in the defense of some older persons accused of CSA. It is also true that some ideas such as a child’s behavior prove sexual abuse or a child who uses a certain color ink in artwork or depicts what appear to be phallic images in art have to have been sexually abused, although passionatey believed by some, were never ideas supported by research. We are not going to review the volumes of research addressing forensic issues in the space allowed for this chapter. We will illustrate below some of that research, much of which has been supportive of children’s capacities to participate in legal processes. False reports. Considerable early interest was focused on how often children make outright false reports of sexual abuse. (See, e.g., de Young 1986; Everson and Boat 1989; Green 1986.) There is general consensus that false reports are rare. Early work by Everson and Boat (1989), examining false reports (4.7–7.6%) in a sample of CPS cases, noted that false reports were more likely in a subset of CPS workers who believed that false reports were common. The authors note that they may be less common in workers who believe that false reports are rare. This points to the power of belief as well as the problem in research and practice of determining what criteria should be employed to judge a report false. A recent review by O’Donohue, Cummings, and Willis (2018), looking at 13 studies on the topic, notes the wide diversity in research in how “false” is defined. Nonetheless, false reports were found in a small number of cases (2% to 5%). Oates, Jones, Denson, Sirotnak, Gary, and Krugman (2000), in a study of Denver Social Services cases over a 1-year period, point out that unsubstantiated does not mean false. Thirty-four percent of cases were determined to be “not sexual abuse” based on social worker judgment, a belief that a parent or relative overreacted, a report from someone in the community later to be

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judged unfounded, and definite fabrication made by an adult (9 out of 185 cases). Although it was thought that a large number of false reports arose in divorce cases, Thoennes and Tjaden (1990), in a review of cases from 12 domestic relations courts over the USA, report that 2% of contested custody or visitation cases involved allegations of CSA. Criteria. The criteria for determining whether an allegation of CSA is true or not have also been the subject of professional interest, in no small part due to suspicion of children as reporters of events in their own lives. At its most basic level, this is a question of professional judgment. Berliner and Conte (1993) early on described the indicator approach (i.e., characteristics of statement from the child, or behaviors of the child or case characteristics). Conte, Sorenson, Fogarty, and Rosa (1991) examined the criteria employed by a sample of 212 professionals. Forty-one criteria were rated for importance. Respondents reported physical medical indicators as the most important criterion (importance index of 84.9), followed by age-inappropriate sexual knowledge (69.3), and consistency in child’s report over time (68.5). Self-mutilating behavior was ranked least important (36.4). As noted by the authors then and more clear now is that indicators of true versus false cases have generally failed to be of much value in part because of limited research that they actually discriminate between true and false cases and because they are largely a matter of professional judgment. Herman (2009) addresses this issue noting that about one-third of all forensic evaluations included uncorroborated verbal reports of CSA by the child. Herman goes on to note that 24–39% of evaluator judgments are in error. And even efforts to create protocols for evaluation still have high error rates. (See Hershkowitz, Fisher, Lamb, and Horowitz (2007a); see also Herman and Freitas (2010).) Everson and Sandoval (2011) note that professional judgments about the validity of child reports of CSA vary and can be accounted for in part by attitudes of the professional (e.g., skepticism about the truthfulness of youth claims). Protocols. The search for something other than the child’s statement of what happened about whether a report is “true or false” has been of interest. In a review Herman (2010) reports on five chart review studies and observes corroborative evidence was present in 35% of 894 forensic cases and in 54% of cases where the professional judged the allegation to be true. At the same time, Walsh, Jones, Cross, and Lippert (2010) examined a sample of 329 cases from the Children’s Advocacy Center in Dallas. Charges were filed in 64% of cases. Types of evidence examined included child disclosure (87%), corroborating witness (46%), offender confession (22%), behavioral evidence (20%), eyewitness account (18%), physical evidence (9%), and psychological evidence (4%). Charges were more likely to be filed when there was a child disclosure, corroborating witness, offender confession, or additional reports against the offender. Behavioral evidence led to charges being less likely to be filed. As noted by Berliner and Conte (1993), another approach has been to develop standards for the professional practice involved in assessing allegations of CSA. In a significant and thorough paper, Faller (2015) reviews developments in the interviewing of children about CSA consistent with this standards approach.

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Although, as noted above (Hershkowitz et al. 2007a), even interviewing protocols based on clear standards can result in errors. Research has examined different interview formats such as the cognitive interview (Milne and Bull 2003) and the National Institute of Child Health and Human Development Investigative Interview Protocol (Sternberg et al. 2001). This interview has received considerable attention. In a 2015 review, Benia, Hauch-Filho, Dillenburg, and Stein report on an analysis of five evaluative studies indicating that the NICHD Protocol increases child informativeness but not so much for preschool children. Interviewed children provided more central details than controls. An extensive review provided by Saywitz, Lyon, and Goodman (2018) of approaches to interviewing children about CSA provides guidelines for the interviewer. These include understanding the importance of nonleading questions and understanding the pressures on children not to disclose; appreciating the risk of suggestibility, especially in very young children; developing rapport with the child; and using language consistent with the child’s grammar and vocabulary. Free recall questioning followed up by more specific questions is preferred. Suggestibility. Research efforts to understand the accuracy of children’s reports in forensic matters has exploded over the last several decades. Gail Goodman has been a consistent leader in these efforts (Goodman and Reed 1986; Goodman et al. 1991; Goodman and Melinder 2007). Without exploring the topic of memory in detail, it is worth noting that memory is influenced by a variety of cognitive and social factors and that events experienced as traumatic tend to be accurately recalled over long periods of time, even when they occur in childhood (see Goldfarb, Goodman, Larson, Eisen, and Qin (2019) for a recent 20-year longitudinal study on childhood experiences of genital contact). Suggestibility has been defined cognitively (“the extent to which individuals come to and subsequently incorporate post-event information into their memory recollections” [Gudjonsson 1986]) and socially (“the degree to which encoding, storage, retrieval and reporting of events can be influenced by a range of social and psychological factors” [Ceci and Bruck 1993]), as noted in Ceci and Bruck’s 2006 review. Their study identifies interviewer bias as the main characteristic of suggestive interviews, with the potential adverse consequences of eliciting inaccurate responses from children or instilling in them false beliefs (e.g., they were not victimized but come to believe they were). Interviewer practices that may introduce bias and contribute to child suggestibility include asking focused or leading questions, repeating questions or interviewing children multiple times, and rewarding or punishing children for their responses, among others (Ceci and Bruck 2006). Goodman, Jones, and McLeod (2017) review areas of contemporary professional consensus on children’s suggestibility and memory in the context of a forensic interview. While the authors caution that research to date still has not produced a way to identify whether a witness in court is right or wrong, two primary themes have emerged regarding the accuracy of children’s reports. These are to acknowledge real limitations and associated challenges with interviewing children, particularly young children of preschool age, and to implement techniques that aim to minimize coercive interviewing practices.

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According to Goodman et al. (2017), interview techniques to increase the accuracy of a child’s reports that have consensus include providing non-contingent support that does not reinforce specific answers, using a science-based protocol (such as the NICHD), having children promise to tell the truth, and asking free recall and open-ended questions, which also increase the likelihood of lengthier responses. Regardless of interviewer efforts to increase the accuracy of reports, it has been widely observed that preschool-aged children are more likely than older children to produce less accurate responses, to respond with less information to free recall questions, and to be more prone to respond inaccurately to misleading questions (i.e., to be more suggestible). While the authors note that young children can give accurate reports (they give an example of a substantiated disclosure made by a 2-year-old girl), part of the difficulty inherent in interviewing children of this age are developmentally related limitations on attention and verbal skills which may lead interviewers to ask more “memory cuing” questions in order to increase the completeness of a report. That these questions may be seen as leading is a widely acknowledged “trade-off” in interviewing younger children, but consensus also exists that they should only be used when necessary (e.g., prompting elaboration on information the child themselves introduced). Other areas of consensus described include the importance of building rapport with the child being interviewed (though the effect of rapport on accuracy of reports remains understudied) and the worth of improving children’s comfort during an interview by allowing them to draw at no risk of decreasing the accuracy of a report (Goodman et al. 2017). A point of professional consensus identified by Goodman et al. (2017) was supported by Saywitz, Wells, Larson, and Hobbs (2019) in a recent systematic review and meta-analysis on child memory and suggestibility. Fifteen studies published from 1991 to 2015 met their inclusion criteria and were identified as being of good quality. The meta-analysis found supportive interviewer behaviors offered in a non-contingent manner increased the accuracy of children’s reports. Interestingly, non-contingent support was also associated with children making fewer errors in response to non-suggestive questions, which seems to indicate positive effects of support on memory.

Summary and Conclusion From the perspective of history, even the short history of the past three or four decades, it is encouraging that less attention is being directed at doubting the disclosures of children and adults abused in childhood. While legal issues involving allegations of child sexual abuse will also be contested, there is increasing research upon which experts, courts, and families can rely. Encouraging disclosure early after a child has been abused deserves considerably more attention as a top priority, as do research to stop abuse after the first incident and, obviously, efforts to prevent abuse from happening.

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Key Points • Disclosure is the child’s report or confirmation that they have had an experience of sexual abuse. Disclosure is a process that is shaped by a variety of barriers and facilitators, takes place over time, and often is delayed until adulthood. It is not uniform and may occur purposely or accidentally. • Forensic practice exists to evaluate claims of abuse arising from disclosure and examine the veracity of the possible abuse experience/s in line with professional protocols, with implications for further legal action. • Identifying and confirming experiences of child sexual abuse through disclosure and forensic practice, respectively, can contribute to the prevention of future abuse.

Cross-References ▶ Sexual Abuse of Children

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Viola Vaughan-Eden, Stacie Schrieffer LeBlanc, and Yvette Dzumaga

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Caregiver Response to Abuse Disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reaction to Disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Types of Frameworks for Understanding Caregiver Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Factors Contributing to Nonoffending Caregivers Reaction . . . . . . . . . . . . . . . . . . . . . . . . . Factors for Improving Reaction to Disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . How to Support Caregivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Engaging Support Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Managing Professional Frustrations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Communicating with Caregivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interdisciplinary Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Therapy for Nonoffending Caregivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Engaging Their Children in Evidence-Based Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. V. Vaughan-Eden (*) Ethelyn R. Strong School of Social Work, Norfolk State University, Norfolk, VA, USA e-mail: [email protected] S. S. LeBlanc The UP Institute, CEO, New Orleans, LA, USA e-mail: [email protected] Y. Dzumaga The UP Institute, Newport News, VA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_15

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Abstract

Child sexual abuse continues to be a significant societal problem. Children’s disclosure of abuse and their degree of recovery are associated with the level of support they receive from professionals as well as their caregivers. While the forensic interview is a critical tool for gathering information in child sexual abuse cases, nonoffending caregivers are integral to the effective investigation and treatment of child victims of sexual abuse. By definition nonoffending caregivers have not sexually abused or directly participated in the abuse of their children. However, nonoffending caregivers are often scrutinized regarding their children’s sexual abuse. Common reactions caregivers frequently express after a disclosure of child sexual abuse are often misinterpreted by professionals. Issues of parental culpability, beliefs, and support in cases of child sexual abuse as well as intergenerational recidivism are discussed. Culturally sensitive investigations and interventions are not only important for successful outcomes but the longterm welfare of the child and family. Effectively engaging caregivers and offering them the necessary resources and services allows them to make decisions that can safeguard their child’s future. Implications for research, practice, and policy are discussed. Keywords

Nonoffending caregivers · Child sexual abuse · Parenting · Abuse disclosure

Introduction Child sexual abuse is a pervasive societal problem. Although it poses a challenge for child protection professionals as well as youth-serving organizations, it leaves many nonoffending parents and caregivers overwhelmed and often suspected of wrongdoing. By definition, nonoffending caregivers are individuals who have not sexually abused or participated in the sexual abuse of their own or other children. They can be mothers, fathers, step-parents, grandparents, aunts, uncles, foster parents, adoptive parents, or siblings; essentially anyone who serves as primary guardian. Nonoffending caregivers span all socioeconomic statuses, races, ethnicities, religions, levels of education, and occupations. Yet, parents and caregivers of suspected sexually abused children often find themselves in a precarious dilemma with social factors and cultural norms obfuscating the issue. The initial shock, ambivalent denial, unanticipated financial burden, and overwhelming grief often leave caregivers struggling to emotionally support their children. Further confounding the situation are the often unrealistic expectations of first responders and victim advocates. Caregivers are usually met with a deleterious community response. Yet, caregiver support is crucial to the investigation and ongoing welfare of the child. The ability of caregivers to support their children can

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be eroded by their own unresolved trauma which may be triggered by the discovery of their child’s abuse. Half of mothers of sexually abused children have experienced or been exposed to childhood sexual abuse (Faller 2007). How well individual children are able to cope with and recover from sexual abuse depends heavily on how well their caregivers, especially mothers, are able to provide support and professional help for them (Corcoran 2004; Everson et al. 1989; Faller 2007; Famularo et al. 1989; Sirles and Franke 1989). Recent research (McGillivray et al. 2018) indicates that nonoffending caregivers’ resiliency can be fostered with social support and self-compassion. However, first responders often lack clarity on which measures are most meaningful to improving a child’s post-disclosure functioning (Bolen and Gergely 2015). When first responders and victim advocates are educated about the research on and needs of caregivers, they tend to broaden their focus to include working with and supporting nonoffending caregivers. Once first responders and victim advocates view caregivers as crucial for effective investigations and aiding in the child’s recovery, they provide more support and resources to the family as a whole, thereby ensuring they receive appropriate interventions. This chapter will discuss nonoffending caregivers’ reactions to child sexual abuse disclosures and the importance of first responders and other professionals engaging caregivers in a supportive and trauma-informed manner.

Caregiver Response to Abuse Disclosure Nonoffending caregivers are typically expected to believe and support their child after sexual abuse disclosure, but oftentimes their reactions can range from anger to complete denial, particularly when put in the context of their experiences. Nonoffending caregivers with a personal history of child sexual abuse report a great deal of self-doubt with their life skills and abilities, anxiety in parenting their children through developmental phases that they had difficulty going through, and feelings of anger that they were unable to protect their children from harm. When hearing about their child’s abuse, they become triggered by their own histories and memories of sexual abuse. They may compare what limited information they know about their child’s disclosure and experience to their own memories and make inaccurate judgments. Due to these complexities, along with numerous other routine obligations, nonoffending caregivers have a variety of reactions to abuse disclosure. While it can be confusing for a first responder to comprehend, a nonoffending caregiver’s preoccupation with seemly mundane activities is a coping strategy. For example, they may be focused on their child making a sports practice when there has been a disclosure of rape. However, rather than judge, it is essential to give not only the child victim but the nonoffending caregiver time to process and to cling to routines of things they can control. It is imperative that all disclosures by nonoffending caregivers be dealt with the same empathy given to the disclosing child and with referrals for available evidence-based therapeutic services.

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Reaction to Disclosure Empowering the nonoffending caregiver during the investigation has been shown to improve outcomes and decrease trauma. Caregivers’ reactions ranging from supportive, suspicious, and unresponsive are confusing to first responders whose primary focus is the safety and well-being of the child. They may unintentionally complicate matters by shaming and alienating the nonoffending caregiver. While keeping in mind that caregivers may express a variety of reactions during the course of their child’s disclosure, overall their presence is of paramount importance to a child in crisis as well as the child’s long-term recovery. Supporting a child’s disclosure is important during the investigation, both for forensic purposes and establishing a long-term path to recovery. Seventy-one percent of five-year-olds kept a secret when told to by an adult, and many children fear that they will not be believed or helped if they disclose (Paine and Hansen 2002). Educating parents on how perpetrators use these tactics to exploit and keep children silent can improve caregivers’ understanding of their child’s experience. Nonoffending caregivers need supportive first responders who empathize with their secondary victimization and explain why children delay disclosing (Münzer et al. 2016). Explaining how to best encourage without tainting disclosure increases transparency in this issue. Current professional wisdom often directs parents not to question or talk to the child about the disclosure but fail to explain what they should do instead. Nonoffending caregivers need clarity on how to be supportive while not interfering with the investigation. Giving parent a printed list of supportive statements on what to say and not say can be quite helpful in times of extreme stress. It is important that first responders acknowledge the additional stressors faced by nonoffending parents such as lack of social support and competing needs of providing for siblings of the abused child. Households with multiple children may have higher rates of abuse, even when accounting for socioeconomic class (Sedlak et al. 2010). Asking the nonoffending parent about their competing concerns, showing empathy, and offering victim support services can be paramount to building a trusted professional relationship. Crime victim assistance is available in all states and offers a range of supportive services that nonoffending caregivers and their children could benefit from if made aware. Yet, nonoffending parents often have a sense of information overload which impedes their ability to hear or to act upon instructions given by professionals. They may require assistance in following through with calls for services instead of just handing them a number to call later. When first responders provide more direct guidance, they will likely have a greater impact on caregivers’ ability to support their children. In cases with adolescents, additional patience and time must be spent with the nonoffending caregivers to help them accept and understand that teenagers are as vulnerable to sexual predators as younger children and should not to be blamed for delays in disclosure. Older children who are abused sexually are often seen as more responsible for their own abuse, while nonoffending caregivers are seen as more

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responsible for the abuse of younger children (Back and Lips 1998). Nonoffending caregivers also need support to build self-compassion to foster their own resilience while reducing feelings and perceptions of self-blame and hindsight second guessing (McGillivray et al. 2018). Familial pressures can have an effect on a child’s willingness to disclose, recant, or minimize past disclosures (Malloy et al. 2007). Children who disclosed before a forensic interview are more likely to disclose during a forensic interview, especially to professionals with whom they have developed rapport (Azzopardi et al. 2019). However, children often delay disclosing when a family member is involved because they anticipate a lack of stable care and nurturing from their parents (GoodmanBrown et al. 2003). Young children are most likely to disclose sexual abuse to mothers and peers, in an accidental or more informal manner, while older children rely more heavily on friends, as parental supervision declines (Manay and CollinVézina 2019). Children disclose stranger abuse most rapidly, especially as the abuse happens at an older age, and are most likely to disclose to close friends (Smith et al. 2000). Some children may not disclose to nonoffending caregivers at all, because they feel that they will not be supported or believed. When investigators discover corroborating evidence, such as sexually transmitted infections, it may be prudent to privately discuss with caregivers and giving them time to process the information as their emotional reactions or further denial may be difficult for disclosing child to process (Lawson and Chaffin 1992). Furthermore, some victims of child sexual abuse were found to not disclose if they did not trust they would receive protection post-disclosure (Münzer et al. 2016). Nonoffending caregivers should be informed of who their children view as potential recipients of disclosure, and support staff should consider differentiating between emotional and informational support. Involving nonoffending caregivers by explaining these tendencies and understanding their child’s relationships may help progress the investigation. First responders and victim advocates can enhance this process by explaining to caregivers that it is normal for children, even with the best of parents to delay disclosing or to tell a trusted friend or teacher first. It is also important in helping parents overcome feelings of shame they may feel because their child did not tell them first or immediately disclose as they had instructed their child to do should anyone ever touched them. Even if the nonoffending caregiver is struggling with denial, minimization, or ambivalence regarding a belief in the child’s allegations, they should still be relied upon in their role as a supportive figure and to provide an ongoing safe environment (Bolen and Lamb 2004). Parental support has been repeatedly shown to be a protective factor for child survivors of sexual abuse. Adult and child survivors that have experienced nonoffending caregiver support conveyed psychological as well as better partner relations later in life comparable to non-abused participants (Godbout et al. 2014). Furthermore, even preschoolers who have been abused may feel a sense of betrayal and show less empathy, help, and comfort themes in their narratives, which may lead to a cycle of the nonoffending parent showing decreased support and voicing negative messages (Langevin et al. 2019).

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Although it is ideal to have both parents involved in the process, research has shown that having a nonoffending father’s support post-abuse may help improve the child’s self-esteem and behavior problems more than a nonoffending mother’s support (Crocetto 2018). On the other hand, nonoffending mothers’ support has been found to reduce the child’s dysfunction in the aftermath of sexual abuse, particularly in foster home placements (Leifer et al. 1993). Parents who find it difficult believing and supporting their child post disclosure, despite first responders and advocates attempts, should be targeted by teams and practitioners to bring awareness to their concern and explore reasons for it, whether cognitive, affective, or social (Cyr et al. 2014). Multidisciplinary team reviews that encourage the sharing of expressed and perceived obstacles to nonoffending caregiver support and the sharing of what has been communicated in the attempt to overcome such will likely have more success in serving child survivors and holding offenders accountable. Plus the sharing of information will reduce redundancy and ultimately ease work load.

Types of Frameworks for Understanding Caregiver Reactions While there is no one type of reactions that are experienced by or displayed by nonoffending parents, grouping nonoffending caregiver reactions into frameworks has been attempted by many different sets of researchers. One framework by Cy et al. (2013) provides the following four categories for grouping support profiles of nonoffending caregivers: resilient, avoidant-coping, traumatized, and anger-oriented. These profiles can be helpful for professionals in responding. Understanding these four categories can equip professionals with limited resources and awareness to better prepare to serve and identify some typical types of reactions a parent may experience or vacillate between. Tailoring approaches has been shown to decrease dropout rate for ongoing services (Cyr et al. 2013). Additionally, nonoffending caregivers frequently vacillate through stages of reactions similar to stages of grief. Professionals must be prepared to respond in accordance with nonoffending caregivers’ fluctuating reactions. Another framework has been described for understanding reactions of nonoffending fathers. Nonoffending fathers have been found to have a variety of factors influencing their reaction to disclosure: guilt, anguish, stigma, hypervigilance, competing demands, lack of trust, refocusing on family, and “picking up the pieces” (Vladimir and Robertson 2019). Following the immediate disclosure of child sexual abuse, nonoffending parents most often feel guilt and blame from failing to protect their child, and initial reactions can range and vacillate (Hébert et al. 2007; van Toledo and Seymour 2013). Some caregivers are less capable of addressing their child’s emotional needs, and react with anger and resentment (Cyr et al. 2013). Others may doubt their child due to preexisting assumptions about abuse and delays in disclosing, leading to reactions characterized by confusion and doubt (Bolen and Gergely 2015). Reactions of denial and disbelief are common when the parent does not want the abuse to be true, and

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therefore copes with reality by denying its existence (Elliott and Carnes 2001). The another typical reaction is guilt and self-blame, where the nonoffending caregiver feels that they have failed to protect their child (Holt et al. 2014). These four support types have been also been framed and summarized as emotional, blame/doubt, vengeful arousal, and skeptical preoccupation (Zajac et al. 2015). These four emotional reactions can be outlined on a graph showing a progression from did not know/supportive to knew/participating/perpetrating, which can further explain how a nonoffending caregiver might feel throughout the disclosure and investigation process. Additionally, nonoffending caregivers may go through the classic stages of grief, cycling through shock/disbelief/denial, anger/resentment, bargaining, depression/ discouragement, and finally acceptance/adjustment (Jones et al. 2010). Contrary to prior belief, grief processing does not happen linearly and caregivers may move from one stage to another without progressing through them sequentially. One more framework described in the literature characterizes caregiver reaction from the perspective of the responding professionals. Professionals scrutinized nonoffending caregivers in four ways after disclosure: belief or disbelief in the child’s allegations, emotional support, response toward the alleged perpetrator, and use of professional services to seek help (Everson et al. 1989). Professional services for nonoffending caregivers focus on both emotional and basic living support, including concerns about finances and shelter. Also, it is important to keep in mind that a nonoffending caregiver’s reaction may not be a valid representation of their overall capacity for support, since they are likely experiencing severe distress from the allegations or abuse findings (Bandcroft et al. 2011; Ovaris 1991). Even the most highly functioning caregivers may become overwhelmed and incapacitated upon learning that their child has been sexually abused (Vaughan-Eden 2014). Their secondary traumatization or triggered memories of personal trauma can impact their parenting style (Bux et al. 2015).

Other Factors Contributing to Nonoffending Caregivers Reaction Aside from the described frameworks grouping reactions to disclosure, nonoffending caregivers may also have a desire to protect the offender, fear domestic violence, struggle with substance abuse or mental health issues, as well as worry about their financial stability. Mothers who appear somewhat supportive can be perceived as showing a lack of support through vacillating ambivalence, when they are in fact attempting to cope with the stress of disclosure while maintaining their daily life (Bolen and Lamb 2004; Bolen and Lamb 2007). Maternal support is not a fixed measure, but is fluid and can be influenced with intervention (Malloy and Lyon 2006). For example, even when mothers held the perpetrators responsible for the abuse, they had difficulty providing emotional support and obtaining professional services for their children (Deblinger and Heflin 1996). While the reactions of nonoffending caregivers vary in response to abuse disclosure, several factors influence how capable the caregiver may feel in the situation.

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Strong maternal support has been found to be more likely from mothers who are adults when they have children, are not sexually engaged with the abuser, and do not see sexualized behavior from their child (Pintello and Zuravin 2001). Lack of maternal support was associated with a history of substance abuse and mental health issues (Vaughan-Eden 2003). Substance abuse issues are correlated with criminal behavior, while mental health issues are more likely with a history of child sexual abuse (Vaughan-Eden 2003). Nonoffending parents who have a history of child sexual abuse make up the vast majority of women who have child victims of sexual abuse (Deblinger et al. 1993; Friedrich 1991; Hébert et al. 2007). Literature is unclear on the extent to which nonoffending mothers’ own history of sexual abuse influences their ability to protect their children from abuse and respond constructively to abuse situations (Kim et al. 2007; Leifer et al. 1993; Parr 2010). Mothers without a personal sexual abuse history were three times more amenable to believing and protecting their sexually abused children than parents with a reported history (Pintello and Zuravin 2001). Mothers with a history of childhood sexual abuse experience greater emotional distress following their children’s disclosure, and typically lacked social support to adequately cope with the disclosure (Hiebert-Murphy 1998). These mothers may minimize the impact of their child’s trauma if they used minimization to cope with their own abuse. The quality of care given by these mothers and their ability to establish a productive working relationship with child protective agencies were significant predictors of their children being re-molested in the future (McDonald and Johnson 1993).

Factors for Improving Reaction to Disclosure Mothers of sexually abused children experience less distress during the investigation when they have support from family and friends, using active behavioral and cognitive strategies to process the abuse instead of avoidance (Hiebert-Murphy 1998). Nonoffending caregiver support at the time disclosure is crucial in how the investigation proceeds and how the child is able to cope, and later recover, from their abuse. A caregiver’s ability to believe and support their child following disclosure has a positive effect on the child’s future psychosocial well-being. Sexually abused girls were shown to be more resilient when they had a warm and supportive relationship with the nonoffending caregiver (Spaccarelli and Kim 1995). Additionally, children receiving evaluation or treatment as soon after the disclosure as possible have been shown to have more positive outcomes. Non-supportive reactions from nonoffending caregivers led victims to be highly stressed and experience severe emotional distress (Spaccarelli 1994). When mothers completely believe their children after disclosing abuse, these children go on to have lower risk for tobacco and illicit drug use. When mothers only somewhat believe the child, the child exhibits increased levels of trauma symptoms (Bick et al. 2014). Nonoffending maternal blame and doubt was also associated with child dissociative symptoms (Wamser-Nanney 2018).

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How to Support Caregivers Mothers often experience close scrutiny and unrealistically high expectations from peers and professionals working with their children. Coupled with their instinctive reaction to the abuse, they may experience shame at failing to meet those standards with professionals (Vaughan-Eden 2014). Some agree, arguing that nonoffending mothers are as much the victim as their children, while others question if they contributed to the abuse (Vaughan-Eden 2014). Prior to 1975, literature suggested that mothers were culpable for the abuse of their children, while others focused on the impact of childhood sexual abuse on mothers’ parenting practices (Myers et al. 1999). Nonoffending parents who are blamed for their child’s abuse can be impeded from being able to support them afterwards (Theimer and Hansen 2017). Nonoffending caregivers are seen as less responsible guardians when children are described as having an abuse incident, regardless of behavior problems (Theimer and Hansen 2017). Nonoffending mothers often received blame from others due to the perception that she must have been negligent for the abuse to occur (Leonard 2013). One study utilized a survey that characterizes nonoffending caregivers across two axes – emotional support and blame/doubt – can provide meaningful insight into whether the caregiver is able to support their child during the investigation (Smith et al. 2010). In another questionnaire, caregivers were able to identify their need for child behavior management and self-coping mechanisms post disclosure (van Toledo and Seymour 2016). Responding professionals can assist by monitoring and addressing the four areas have been identified for consideration when assessing maternal support: the mother’s belief in the child’s abuse allegation, the mother’s level of emotional support of the child, the mother’s actions toward the perpetrator following the disclosure, and the mother’s use of professional services (Everson et al. 1989). Investigators during the process can benefit from understanding how nonoffending mothers are subject to immense pressures to protect their child and be expected to be their support. Having professional self-awareness of frustrations that arise during the process, especially across a wide range of nonoffending parental reactions, is beneficial for the caregiver and the investigator. Establishing clear lines of communication with respect for cultural differences lays a strong foundation for a working relationship. Giving nonoffending caregivers options where available to influence the course of the proceedings, and advising on physical needs can help alleviate pressure and improve the path to recovery. Providing therapy to nonoffending caregivers may also empower them to support their children (Corcoran 1998). Engaging in interdisciplinary teams and having at least one professional support for the nonoffending caregiver from the initial investigation until the resolution may improve outcomes (Elliott and Carnes 2001). Finally, continuing professional education for investigators, advocates, and all members of multidisciplinary teams will help ensure that best practices are being met and followed during the process.

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Engaging Support Systems At baseline, child sexual abuse strains relations within a family. Nonoffending caregivers with abused children have more family disengagement, less partner relationship satisfaction, and more chaotic functioning (Cabbigat and Kangas 2018). Increasing social support is core to increasing the resilience of the nonoffending caregiver to be able to support their child (McGillivray et al. 2018). In light of potential familiar strain, helping nonoffending caregivers to be able to reach out to other support systems such as friends, neighbors, and faith-based resources may be critical in their ability to exhibit the needed resilience to support their children. Also offering available clinical services and adult educational curriculums on the prevention of child sexual abuse such as Darkness to Light, Enough Abuse, or Stop it Now for the extended family may help reengage needed familiar support for nonoffending caregivers.

Managing Professional Frustrations For professionals involved in investigating, advocating, or serving on teams addressing child sexual abuse, it is critical that all exercise self-awareness of frustrations arising from varying nonoffending caregiver reactions. By being aware of frustrations in advance of the interaction, the professionals may positively impact the professional-caregiver relationship. Professionals should expect to stabilize the situation without blame or judgment, normalize feelings and responses, respond to the nonoffending caregiver in a supportive manner regardless of their reaction, and acknowledge possible divided loyalties. By approaching the nonoffending caregiver with these reactions in mind, the professional can set up a longer-term positive relationship with the caregiver, which can ultimately aid in minimizing trauma to both the child and the nonoffending caregiver.

Communicating with Caregivers First responders have been shown to aid in supporting nonoffending caregivers when they treat them with respect, communicate effectively, validate their reality, advocate for them, empower them to make choices about outcomes, and educate them about the investigative and recovery pathways. In addition to these general guidelines, it is crucial to consider cultural differences, establish support systems, collaborate across multidisciplinary team members while involving the nonoffending caregiver, and educating them about both their options and possible actions to safeguard their child’s future. Nonoffending caregivers should be educated about normal developmental milestones in sexual behavior, asked about their own history of abuse, and questioned about relationship issues to further understand and document the situation (VrolijkBosschaart et al. 2018). Social workers can also benefit from focusing on engaging

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nonoffending fathers, who have typically been an overlooked segment in the care cycle (Crocetto 2018). Parenting practices regarding discipline and addressing undesirable behavior must be explored. Helping parents understand that children impacted by adverse childhood experiences may be perceived as misbehaving. Professionals who take the time to communicate the potential harms of using corporal punishment and providing educational parenting resources by developmental age serve a key informant for nonoffending parents to support their abused children. Awareness of cultural differences is crucial for establishing a supportive relationship with nonoffending caregivers. Maintaining an open and curious approach when interacting with caregivers, particularly from a minority culture, is important when overcoming cultural challenges (Alaggia 2002). Cultural sensitivity is increased by assuming and exploring the nonoffending caregivers’ strengths rather than making assumptions. Recognizing pride and strength despite non-supportive responses is imperative to build the trust and relationships needed to encourage engagement in exiting services. Pretreatment with one-on-one counseling with nonoffending caregivers to encourage them to share their experience has been shown to improve support for their children (Alaggia 2002). Nonoffending caregivers benefit from investigators increasing their communication about limitations and reasoning behind interviews, decisions made, and timelines on their cases (Jones et al. 2010). Nonoffending caregivers seeking help have been shown to preferentially reach out to social workers and psychologists, with 2/3 of them preferring in person counseling. Law enforcement, investigators, and prosecutors who utilize available multidisciplinary team members to assist with communication and providing needed social support for nonoffending caregivers will be likely be more successful than proceeding alone (Jones et al. 2010). Families often complain about lack of care continuity with intervention services (Hernandez et al. 2009). In line with increasing communication regarding options for nonoffending caregivers, these caregivers have been shown to be more satisfied with the investigation when conducted at a children’s advocacy center (Jones et al. 2007). Children’s advocacy centers help systematize, and therefore minimize harm during the investigation of child sexual abuse (Tavkar and Hansen 2011). Child advocacy center based treatment programs have the greatest potential for meeting the needs of victims and families (Tavkar and Hansen 2011). They provide an opportunity for the entire team of professionals to coordinate from the beginning of the investigation and legal proceedings, through treatment (Bonach et al. 2010). At children’s advocacy centers, there is a possibility of providing resources such as education, financial training, job skills training, and effective parenting without harm, which can be done in collaboration with treatment providers and overall establish a sense of empowering the family and restoring a sense of purpose in the community (Vaughan-Eden 2014). Child advocacy centers should be used when investigating child abuse claims; these centers can also educate and involve nonoffending caregivers and non-abused children in the family. Professionals should be aware that households in which abuse has taken place may also have assistance requirements, which the nonoffending caregiver may or

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may not disclose, and which may help decrease trauma and increase recovery speed if addressed promptly. Nonoffending caregivers may believe that it is therapeutic to present themselves positively and deny their own abuse or common parenting challenges in an effort to keep their children remaining at home (Vaughan-Eden 2014). In these situations, it is important to bring up the topic of physical assistance independently of the caregiver asking for help. Social workers helping support nonoffending caregivers post child disclosure should be aware that a significant portion of caregivers need physical assistance, such as food, shelter, and income (Massat and Lundy 1999). Parental separation or moving homes may cause additional anxiety surrounding disclosure. Families with younger victims or spousal abuse were more likely to separate (Spaccarelli 1994). A dysfunctional family environment was shown to lead to more trauma symptoms following child sexual abuse disclosure (Yancey and Hansen 2010). Additionally, nonoffending caregivers should be asked about their language preference and if their language of origin is not English they should be given a choice of having a professional interpreter’s service. Nonoffending caregivers with limited English must be provided adequate professional interpreter services. Children should never be utilized to interpret. If a nonoffending parent expresses that they wish to use a friend or relative as an interpreter, it should be discouraged but if necessary, confirmed and documented with an independent professional interpreter prior to assuming any confidential communications.

Interdisciplinary Collaboration Interdisciplinary team collaboration is vitally important when working with victims of child sex abuse. Collaboration begins before investigating a case, with training together and having processes in place that consider the goals of multiple team members during the investigation. While investigating, interdisciplinary collaboration is crucial from the beginning, during initial forensic interviewing, to the end, when testifying in court. Having a strong understanding of and involvement with the process from start to finish promotes a more organized approach and better handoff of care for the clients involved. The approach of the investigating team informs how the clients experience trauma and eventually feel empowered to recover. There is a need for frontline workers to be unified in response to victims of childhood sexual abuse, with a consistent and organized system of gathering information, referring agencies, and providing resources. By viewing the nonoffending caregivers and their children as part of the team, professionals encourage stronger outcomes (VaughanEden 2014).

Therapy for Nonoffending Caregivers While it is common for the child sexual abuse victim to be referred for evidencebased therapy, recent research has also focused on the necessity of providing therapeutic services for the nonoffending caregiver. Both receiving individual

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therapy and involving the nonoffending caregiver in therapy with the child may help the parent and child, especially when not all symptoms are initially identified, and the family system may be disrupted through intra-family abuse (Corcoran 2004). Certain parents are more vulnerable to psychological and physical symptoms following disclosure; they should engage with services for an extended period. Symptoms of post-traumatic stress disorder tend to wane over time in nonoffending caregivers, so ability to identify signs early may lead to improved outcomes (Cyr et al. 2018). Additionally, engaging in a parent group for sexually abused children helps decrease the silence typical of this issue and may help decrease symptoms of post-traumatic stress disorder, increase family functioning, and increase motivation for helping their child recover (Hernandez et al. 2009). It was found that nonoffending fathers use health services such as general practitioners for depression following a child’s disclosure (Cyr et al. 2016). Nonoffending caregivers are at greater risk of depression symptoms following abuse disclosure and were found to have more abuse specific cognitions than caregivers without those cognitions (Runyon et al. 2014). Additionally, caregivers with reported depression or anxiety showed more conflict and distant relationships with their children (Cabbigat and Kangas 2018). Professionals aware of this trend may identify and suggest services to parents following disclosure, and potentially capture a larger proportion of nonoffending caregivers with depressive symptoms that could greatly benefit from this attention. Research has found that cognitive behavioral therapy as a joint parent-child intervention may lead to better adjustment in the parent and child (Elliott and Carnes 2001). Providing therapy for a nonoffending caregiver has been shown to result in fewer psychological symptoms and emotional reactors in the caregivers, while decreasing observed and reported depressive, fearful, aggressive, and sexualized behavior in children (Yancey and Hansen 2010). These caregivers report less depressive, fearful, anxious, and guilty symptoms, which may increase their capacity to support their child and provide a blueprint for recovery (Yancey and Hansen 2010).

Engaging Their Children in Evidence-Based Therapy Evidence-based therapeutic treatments such as trauma-focused cognitive behavioral therapy commonly called TF-CBT or Stepped Care TF-CBT view nonoffending caregivers as the “central therapeutic agent of change” (Griffin et al. 2019). These proven therapies have demonstrated the largest gains in the shortest time period and recognize that the nonoffending caregiver is the child’s strongest source of healing and is the expert of their child (Griffin et al. 2019). Like these evidence-based therapies, all the professional members of the multidisciplinary team of a children’s advocacy center must also view and convey that the nonoffending caregiver is the leading expert on the child. This can be difficult for the experts who are serving the family but crucial in building the child’s strongest source of long-term healing. Other benefits of the trauma focused cognitive behavioral therapy include emphasis on increasing effective and positive parenting practices. Multidisciplinary teams

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that share concerns about a nonoffending caregiver’s parenting skills can be assured that efforts to encourage the nonoffending caregiver to engage and complete therapy will also address those general parenting concerns. In fact, the eight main components of trauma-focused cognitive behavioral therapy is spelled out as PRACTICE – “Psychoeducation and Parenting skills; Relaxation skills; Affective regulation skills; Cognitive coping skills; Trauma narrative and cognitive processing of the traumatic event(s); In vivo mastery of trauma reminders; Conjoint child-parent sessions; and Enhancing safety and future developmental trajectory” (Cohen and Mannarino 2008, p. 159). The parenting skills component allows therapists to work collaboratively with parents to teach basic parenting skills to support their traumatized child. Additionally, evidence-based therapy will help the nonoffending caregiver develop positive self-talk and build their confidence and competence in helping the child heal and being the child’s go to person. All professional contacts with the nonoffending caregiver must be aware and communicate the need and benefits of completing trauma-focused therapeutic services. While most nonoffending caregivers initially recognize the need for therapy, many do not follow through with making the initial appointment or completing the therapy. Yet, Children’s Advocacy Centers and multidisciplinary teams sometimes operate as though having free access to therapy, and giving the nonoffending caregiver a number to call will address the problem. The research indicates more needs to be communicated and done to assure that the first appointment is made and therapy is completed. Without this united emphasis and follow-up of all professionals, many nonoffending caregivers do not make the initial appointment. The reasons for not engaging are vast but one that is now frequently addressed is that the nonoffending caregiver does not recognize the need. Some believe that not talking about it or forgetting about, as they may have dealt with their own trauma, is the most effective way to deal with trauma. The multidisciplinary professionals should help the nonoffending caregivers understand the impact of child sexual abuse can be substantial if the child does not complete evidenced based therapy. The message must include that the impact of child sexual is serious but there is substantial hope for full recovery if therapy is completed. Additionally all professionals and first responders must address that the impact of child sexual abuse sometimes has “sleeper effects” that do not manifest for years after initial disclosure. Nonoffending caregivers and family may mistakenly perceive the child’s behavior as “OK or normal” and perceive therapy as making the child’s behavior and affect worse. As a result, between 20% and 60% of therapeutic relationships terminate prematurely (Griffin et al. 2019).

Summary and Conclusion Child sexual abuse remains an evolving field. As new research becomes available, continued professional development is important for those working with suspected child abuse victims and their caregivers. What we believed 20 years ago has changed in light of ever-increasing research in the field and enables those working with

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nonoffending caregivers to provide the best possible care. Practitioners who remain self-aware of emotional frustrations, as well as educating oneself in the field, allow professionals to be supportive and successful. It is important for professionals to remain up-to-date on the latest research. Knowledge of programs that automatically place caregivers in education/support groups, child advocacy centers that have family advocates on staff and simultaneously provide services, as well as provide a list of community resources are imperative. Connecting the nonoffending caregiver with therapeutic services and other community resources early has been shown to decrease familial trauma post-disclosure. In summary, the complexity of investigating and preventing child sexual abuse must include a greater acceptance of the crucial role nonoffending caregivers have in the child’s recovery. Multidisciplinary teams that spend equal time collaborating on supporting the nonoffending caregiver as they focus on gathering evidence will be more successful in assuring recovery of child sexual abuse and holding adult offenders accountable. Fostering resilience in nonoffending caregivers will ultimately serve the child survivor in the long-term more than focusing on nonoffender caregivers’ predictable yet distressing reactions and behaviors. Nonoffending caregivers’ resiliency can be fostered by increasing social support and self-compassion (McGillivray et al. 2018). Recognizing and offering support and therapeutic services for the nonoffending caregivers’ untreated trauma will aid the child’s recovery and the ability of the caregivers to provide ongoing care. Nonoffending caregivers are the key to carrying out effective trauma informed investigations and aiding in the child’s overall well-being.

Key Points • Nonoffending caregivers are integral to the effective investigation and treatment of child victims of sexual abuse. • How well individual children are able to cope with and recover from sexual abuse depends heavily on how well their caregivers are able to provide support and professional help for them. • Caregivers’ reactions ranging from supportive, suspicious, and unresponsive are confusing to first responders whose primary focus is the safety and well-being of the child. • Nonoffending caregivers may go through the classic stages of grief, cycling through shock/disbelief/denial, anger/resentment, bargaining, depression/discouragement, and finally acceptance/adjustment. • Nonoffending parents who have a history of child sexual abuse make up the vast majority of women who have child victims of sexual abuse. • Nonoffending parents who are blamed for their child’s abuse can be impeded from being able to support them afterward. • For professionals involved in investigating, advocating, or serving on teams addressing child sexual abuse, it is critical that all exercise self-awareness of frustrations arising from varying nonoffending caregiver reactions.

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• Awareness of cultural differences is crucial for establishing a supportive relationship with nonoffending caregivers. • Interdisciplinary team collaboration is vitally important when working with victims of child sex abuse. • Multidisciplinary teams that spend equal time collaborating on supporting the nonoffending caregiver as they focus on gathering evidence will be more successful in assuring recovery of child sexual abuse and holding adult offenders accountable.

Cross-References ▶ Adult Sex Offenders Against Children: Etiology, Typologies, Investigation, Treatment, Monitoring, and Recidivism ▶ Adverse Childhood Experiences: Past, Present, and Future ▶ Child Sexual Abuse Disclosure and Forensic Practice ▶ Mother-Child Attachment in Violent Contexts: Effect of Complex Trauma and Maternal Trauma History ▶ Overview of Child Maltreatment ▶ Sexual Abuse of Children

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Victor I. Vieth Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Critical Importance of Accessing Quality Resources and Expertise . . . . . . . . . . . . . . . . . . . . . . Developmentally Appropriate Sexual Behaviors: Preadolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Children Below the Age of Four . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Children Ages Four to Six . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Children Seven to Twelve Years of Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concerning Sexual Behaviors: Preadolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Developmentally Appropriate Sexual Behaviors: Adolescence and Teenage Years . . . . . . . . . . . Developmentally Inappropriate/Deviant Sexual Behaviors: Adolescence and Teenage Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Deviant Level One . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Deviant Level Two . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Deviant Level Three . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What Causes Adolescents and Teenagers to Commit Sexual Offenses? . . . . . . . . . . . . . . . . . . . . . . . Treatment for Juveniles Who Commit Sexual Offenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Role of Schools in Addressing Problematic Sexual Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . The Risk of Re-offense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A Hypothetical Case Study on Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Re-uniting Siblings When There Has Been a Sexual Offense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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A portion of this article was originally published in Volume 45, issue 3 of the Currents in Theology and Mission in July of 2018 and is reprinted here with permission. A number of revisions and significant additions have been made to this draft. This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. V. I. Vieth (*) Education and Research, Zero Abuse Project, St. Paul, MN, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_27

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Investigative Challenges in Responding to Problematic Sexual Behaviors of Children . . . . . . Investigative Challenges: Questioning Child Offenders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Investigative Challenges: Compliant Victims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Investigative Challenges: Peer Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

This chapter provides an overview of developmentally appropriate and inappropriate sexual behaviors for preadolescent and postadolescent children. In addition to providing an overview of scholarly work on this subject, anecdotes illustrating the research are provided. Potential causes for problematic sexual behaviors are explored as well evidence-based treatment options. Unique issues facing educators, forensic interviewers, and other professionals are discussed and an outline is presented of factors to be considered when reuniting siblings when there has been a sexual offense. Challenges facing MDTs investigating these cases are also discussed. Keywords

Juvenile · Adolescent · Sexual behaviors · Treatment · Reunification · Forensic interviews

Introduction A concerned parent visits a teacher or other trusted professional because she is unsure what to make of her kindergartener touching the genitals of his baby brother. A youth minister overhears a confirm and making explicit jokes about sexual assault with his friends. A group leader for a youth serving organization walks into a women’s restroom and discovers a 7-year-old girl licking the vaginal area of a 5-year-old girl. These are all actual cases arising in myriad communities. When these and similar cases come to the attention of professionals working with youth, we are often unsure how to respond and, as a result, even seasoned professionals may ignore concerning behaviors and overreact to behaviors that are developmentally normal. Although this chapter cannot fully address the complexities involved in the sexual behaviors of children, it can provide an overview of the subject and offer guidance for obtaining additional information. To this end, the chapter introduces the reader to quality resources that can assist when addressing this issue. The chapter also provides an overview of normal and concerning sexual behaviors among children. Guidance is offered on appropriate interventions or treatment when behaviors are

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concerning. The role of schools and the unique challenges facing multidisciplinary team (MDT) members responding to a sexual assault committed by a child are also discussed. Finally, there is a discussion of factors to consider when a juvenile has been removed from his or her home because of sexual misconduct and is being re-integrated into a home, school, youth-serving organization, or other setting.

The Critical Importance of Accessing Quality Resources and Expertise When confronted with the sexual behaviors of children, child protection professionals and the families they serve should take two critical steps. First, it is important to review quality information about the sexual behaviors of children. The National Center on the Sexual Behavior of Youth (NCSBY 2019), the National Childhood Traumatic Stress Network (see resource section), and the American Academy of Pediatrics (Kellogg 2009) have all published free, online materials that can help in determining when a behavior is concerning enough to warrant professional intervention. The SMART Office of the United States Department of Justice has published a free, online summary of peer reviewed studies on juveniles who commit sexual offenses and evidence-based treatment (SOMAPI 2019). (SMART stands for Office of the Sex Offender Sentencing, Monitoring, Apprehending, Registering and Tracking.) Second, it is important to consult one or more experts on the sexual behaviors of youth. Reaching out to hospitals that are part of the National Childhood Traumatic Stress Network or Child Advocacy Centers (Chandler 2006; National Children’s Alliance 2019) are good places to start. These institutions and programs can likely direct a parent, teacher, or youth serving professional to an expert in this area who can assist a family struggling with this issue. Indeed, youth serving organizations should make these contacts long before a crisis arises so that when concerning behaviors present themselves, a list of referrals to area experts is readily at hand.

Developmentally Appropriate Sexual Behaviors: Preadolescence More than half of children will engage in sexualized behavior before they turn 13 with some research placing this number much higher (Kellogg 2009). Most of this behavior is “informational gathering” as children “explore each other’s bodies by looking and touching (e.g., playing doctor) or exploring gender roles (e.g., playing house)” (Johnson 2015, p. 1). Adults see sexual activity based on our grown-up experiences of sexual desire and orgasm-seeking behaviors. While preteens may be motivated by more adult-like desires, “this is rarely true of young children” (Johnson 2015, pp. 5–6). Instead, these children view private parts as a “mystery and secrecy that inspires them to discover what they are all about” (Johnson 2015, p. 6).

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Children Below the Age of Four Applying this knowledge to children less than 4 years of age, all of these behaviors would be developmentally normal: • • • • • • •

Exploring/touching private parts in private or public Rubbing private parts with a hand or against objects Showing private parts to others Trying to touch a mother’s or another woman’s breast Removing clothes and wanting to be naked Attempting to see others undressing Talking to same-aged children about “poop” and “pee” (National Childhood Traumatic Stress Network 2019)

If, then, a toddler likes to run through the house naked after a bath or peeks in on a parent when they are showering, or giggles when talking about body functions with other children at his preschool, there is little to be alarmed about.

Children Ages Four to Six For children 4–6 years of age, the NCTSN finds all of these behaviors to be common and developmentally normal: • • • • •

Purposely touching his or her genitals Attempting to see others naked or undressing Mimicking dating behavior (kissing, holding hands) Talking about private parts and using “naughty” words they don’t understand Exploring private parts with children their own age (playing doctor, “show me yours, I’ll show you mine”) (NCTSN 2019, Table 1)

Assume, for example, an adult walks into a room and discovers three girls, all 5 years of age, while their panties are off and giggling and pointing toward and touching each other’s genitals (Johnson 2015). Applying the research above, an appropriate response would simply be to tell the children that it is not a good idea to touch each other’s private parts and to inform them that others are not allowed to touch their private parts (Johnson 2015). With this simple education, the behavior is unlikely to repeat itself. As another example, assume a kindergartner signed up for rec-ball gets a protective cup and comments “I’m so glad we got the cup, you have to protect the family jewels.” In all likelihood, the child has no idea what he is talking about but has likely heard a phrase from television or an older youth and is simply repeating something he sees as “naughty” or perhaps funny. Asking what the child meant, and then answering any questions he may have about the cup is the proper parental approach.

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Children Seven to Twelve Years of Age For children in this age range, the NCTSN concludes the following behaviors are common and normal: • Masturbation but usually in private • Playing games with children their own age (truth or dare, playing family, playing boyfriend/girlfriend) • Looking at pictures of naked people • Viewing/listening to sexual content in media (TV, movies, games, the Internet, music) • Wanting more privacy (when undressing, etc.) • Beginnings of sexual attraction to peers (NCTSN 2019) If, then, an adult walks in on two preteens exploring each other’s bodies, he or she has likely walked in on developmentally normal behavior. In this instance, it would be appropriate to discuss with them the responsibilities of sexual activities, to let them know they are too young to be making babies, and to facilitate a healthy dialogue with their parents (Johnson 2015). In some cultures, it may be appropriate to have a conversation about morality and when it is acceptable or not acceptable within a community to engage in sexual activity. At the very least, it is appropriate to discuss values in a family or community. These values may include appropriate dress, when it is appropriate to hug or kiss another person, when it is permissible for a child to be in bed with an adult, and what language is appropriate when discussing sexual practices (Rosenzweig 2012). It is also important to discuss the potential risks of early sexual activity and the potential benefits of healthy intimacy (Rosenzweig 2012). Giving children an outlet to discuss sexual thoughts and desires and pose questions about the changes in their bodies can be a vehicle for preventing problematic sexual behaviors. In some instances, the questions may pertain to a sexual act. In one case, a child asked his mother about the meaning of the phrase “blow job” (a term he apparently heard at school). A parent who provides a matter of fact answer that this is a slang term for kissing a penis or vagina may get a response from a young child that this sounds gross and wondering why someone would do such a thing. A parent can explain that it is a manner in which some adults express affection for one another. A parent can then explore more about how the child heard the term and determine if anyone may be initiating concerning conversations with a child or posing a risk in any way. It would be problematic, for example, if a much older child or an adult was introducing this term to a young child (Rosenzweig 2012). With respect to morality or values, Janet Rosenzweig notes that many children posing questions about sexuality are “seeking opinions, as opposed to facts” (Rosenzweig 2012, p. 33). According to Rosenzweig, these questions create opportunities to delve into conversations about values. Specifically, she writes:

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From ‘when is it OK to have sex?’ to ‘Why is a girl’s chest considered a private part but a boy’s is not?’ being open and available to your kids’ questions provides a great opportunity to bring your values to your child and to inform them about sexuality, relationships, and peers. (Rosenzweig 2012, p. 33)

Concerning Sexual Behaviors: Preadolescence Although it is true that most children exhibit sexual behaviors, some behaviors are less common and may pose concerns. In a study of 1,142 nonabused children, researchers found the following behaviors were relatively uncommon: • • • • • • • • •

Placing child’s mouth on a sex part Asking to engage in sex acts Masturbating with an object Inserting objects in vagina/anus Imitating intercourse Making sexual sounds French kissing Asking to watch sexually explicit behavior Imitating sexual behavior with dolls (Myers 2005; Friedrich et al. 1991)

In one case, a school teacher at a faith-based school walked into a bathroom and discovered a 7-year-old girl performing cunnilingus on a 5-year-old girl who was pinned against a wall with tears running down her cheeks. (This is a case the author consulted on.) Applying the research above, this would be an unusual sexual activity for a child so young. In addition to the explicit nature of the act, the 2 year age difference and the appearance of some force (pinned against the wall) as well as harm (tears running down a cheek) raise a number of valid concerns. In another case, a 5-year-old boy was observed going up to girls on a playground and asking them to “suck my dick.” (This is a case the author consulted on.) When other children declined, he punched them in the stomach. The explicit request, combined with violence, is unusual and concerning. Although concerning sexual behaviors can be attributable to sexual abuse (Faller 2003; Friedrich 1993), there are also multiple other factors that could be driving the behavior including exposure to pornography and observing adults engaged in sexual activity (Myers 2005). If these other potential sources of knowledge are eliminated, the possibility of sexual abuse increases (Myers 2005). As one example, consider the case of the kindergartner boy discussed above who asked other children to “suck my dick” and then punched them when they declined. When this case was investigated, the boy denied being sexually abused but acknowledged he had been exposed to explicit sexual content. When a social worker and police officer went to the boy’s house, they were unable to freely walk through the house without stepping on pornography. The boy’s milk glass he drank from each morning had a picture of a nude woman performing a sexual act on herself. In the

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father’s bedroom (the child’s mother was deceased), the investigators discovered a nude photograph of dad with an erect penis which was matted, framed, and hanging on a wall. Although it is possible the boy was sexually abused, it is also possible the inundation with sexual imagery caused the boy’s sexually explicit request and violent behavior. In cases of concerning sexual behavior such as the two cases described above, the National District Attorney’s Association recommends screening for the possibility of sexual abuse, noting that the “younger the child is in age, the more likely he is mimicking behavior seen or repeating behaviors the child has experienced” (Ratnayake 2003). Young children exhibiting concerning behaviors should not be charged as juvenile delinquents but if parents are unwilling to provide treatment or other necessary services, the government may consider filing a child protection petition to compel the parents to do so (Ratnayake 2003). Even if parents are willing to cooperate with the authorities, some egregious cases (such as the case of the father inundating his child with sexual imagery) warrant a child protection action and the consideration of possible criminal charges against a parent.

Developmentally Appropriate Sexual Behaviors: Adolescence and Teenage Years In her summary of the literature, Dr. Anna Salter notes the following behaviors to be common and normal among adolescents and teenagers: • • • • • •

Sexually explicit talk with peers Obscenity/jokes within cultural norm Interest in erotica Solitary or mutual masturbation Hugging, kissing, holding hands Foreplay, even intercourse with consenting partner (Salter 2018)

In describing these behaviors as normal, this is not to say parents or other adults should not intervene when young people are making inappropriate comments or engaging in sexual activity. As discussed earlier in this chapter, young people need moral training and assistance in making sexual decisions (Rosenzweig 2012). This is simply to say that the behaviors above do not warrant a call to the authorities or professional intervention.

Developmentally Inappropriate/Deviant Sexual Behaviors: Adolescence and Teenage Years In terms of inappropriate sexual behaviors among adolescents and teens, Dr. Anna Salter categorizes three levels of deviance with each level becoming increasingly problematic.

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Deviant Level One The lowest level of deviance which nonetheless presents concerns includes the following behaviors: • High degree of preoccupation/anxiety about sexual matters • Frequent use of pornography/sex shows (e.g., strip clubs or other performances with sexual overtones or erotic content) • Indiscriminate sexual acts with multiple partners • Sexually aggressive remarks, obscenities, graffiti • Embarrassing others with sexual remarks • Pulling skirts up, pants down • Violating others’ space (Salter 2018) At a minimum, behaviors of this type should not be ignored and they are worthy of a conversation in the hope of providing appropriate boundaries. If the behaviors are extreme, some professional intervention may be appropriate. Some of the behaviors, such as indiscriminate acts with multiple sexual partners, are associated with having endured trauma (Felitti and Anda 2010).

Deviant Level Two The middle tier of deviance includes these behaviors: • Compulsive masturbation (e.g., a teenager who repeatedly excuses him or herself from class to masturbate in a bathroom stall as a means of relieving anxiety) • Degradation/humiliation of self or others with sexual overtones • Attempting to expose the genitals of others • Chronic preoccupation with sexually aggressive porn (e.g., pornography depicting rape or other violence) • Sexually explicit conversation with young children • Sexually explicit threats • Obscene phone calls (Salter 2018) In one case, a teenager was hospitalized after tying a fish line so tightly around his nipples it would take surgery to remove. (This is a case the author consulted on.) In therapy, the child shared that the only way he could be sexually aroused is to harm or humiliate himself. As the case progressed, it was discovered the child had been sexually abused by 17 different adults and he himself had sexually abused multiple younger children. All of these revelations were made possible because professionals realized the concerning sexual behavior of the teenager at the outset and sought professional help. In another case, a teenage boy made comments to teenage girls that were graphic and threatening. For instance, he said to a girl “one day I’m going to get you alone,

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and roll you down the hall like a bowling ball” – a comment suggesting digital penetration of the vaginal and anal openings and causing the girl to fear an eventual sexual assault. The child did, in fact, later commit a sexual assault which resulted in delinquency charges.

Deviant Level Three The most egregious level of adolescent and teenager deviance includes these behaviors: • • • •

Genital touching without permission Sexual contact or penetration (vaginal/anal) Sexual contact with animals Causing genital injury to others (Salter 2018)

The sexual behavior described above would be a crime if committed by an adult and warrants a delinquency petition and full assessment. To get a sense of these types of cases, consider the following three examples. First, a 14-year-old boy has been warned at a church summer camp about sexually aggressive remarks directed toward a girl his age. When he walks past the girl at a youth activity, he takes a pencil and forcibly pokes the girl’s breast, causing her pain. (This is a case the author consulted on.) There are multiple concerning factors in this scenario. The child’s remarks were sexually aggressive and, when warned, he elevates the conduct by promptly committing a sexual assault. The church must take immediate action to protect the victim, report the conduct to the authorities, and insist on a complete assessment that will aid in determining how best the church can work with the youth going forward. Second, four 16-year-old boys from the local high school basketball team are at a hotel for a basketball tournament. (This scenario is modified from a case the author consulted on.) Three of the boys gang up on a boy who is often picked on. While two of the boys hold him to the ground, the third boy attempts to “tea bag” him by putting his testicles in the boy’s mouth. The victim’s yelling causes the basketball coach to walk into the room. Obviously, this is a serious sexual assault that warrants immediate action. The victim needs to be protected and supported. The offenders need to be reported to the authorities and, working with the authorities, the school can decide how best to support the assessment and treatment of the offenders. Third, a parent has a 13-year-old son who has invited several of his teenage friends to his house. The boy persuades his younger sister, only 6 years old, to lie down on the bathroom floor with her pants and panties off. He promises he won’t let his friends into the bathroom but he promptly breaks this promise and he and his friends have a “good laugh” about the matter (Wiehe 1990). Without training, this scenario could easily be dismissed as a silly prank. However, there are numerous factors of concern – the significant age difference, the degree of planning involved, and the intentionality of humiliating his sister in a way that has sexual overtones.

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It is helpful to remember that youth “engaged in extraordinarily violent, and lethal sexual crimes. . .are aberrations” (Miccio-Fonseca 2019). At the same time, it is foolish to ignore that some children, particularly adolescents and teenagers, have committed violent sexual assaults and the field needs to continue to improve its ability to detect this smaller category of high risk juvenile offenders in the hope of intervening effectively (Miccio-Fonseca 2019).

What Causes Adolescents and Teenagers to Commit Sexual Offenses? Determining the cause of sexually abusive behaviors is difficult. Factors contributing to this behavior range from sexual curiosity to serious mental health problems (Finkelhor et al. 2009). According to the Association for the Treatment of Sexual Abusers: Adolescent sexually abusive behavior is influenced by a variety of risk and protective factors occurring at the individual youth, family, peer, school, neighborhood and community levels. Consequently, policies and practices should include evaluations that consider a range of potentially relevant factors that might be related to the development or possibility of repeated sexually abusive behavior in a given youth and that can guide effective intervention. (ATSA 2012)

A juvenile offender’s own history of sexual victimization may play a role, particularly when the offender’s prior abuse occurred at a young age, involved multiple incidents, led to a long waiting period before the abuse was reported, and was followed low level of perceived family support (Hunter and Figueredo 2000). As a whole, though, a history of physical abuse or neglect has a stronger correlation to later sexual misconduct (Widom and Massey 2015). Keep in mind that when children are maltreated, they are often abused in multiple ways (Turner et al. 2010; Finkelhor et al. 2007). In a study of 667 boys and 155 girls who had committed sexual offenses, nearly all of them had “highly dysfunctional” families and many had experienced physical abuse, sexual abuse, emotional abuse, and neglect (Cavanaugh et al. 2008).

Treatment for Juveniles Who Commit Sexual Offenses There are multiple options for treating a juvenile who has committed sexual offenses. Treatments that have some support in the empirical research literature include cognitive behavioral therapy, relapse prevention, sexual trauma therapy, and psychosocial education (Reitzel and Carbonell 2006). Multisystemic Therapy (MST), which operates on the premise that individual, family, and environmental factors all play a role in sexual misconduct, has also proved effective in lowering recidivism (Letourneau et al. 2009).

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Assume, for example, a teenage boy has sexual fantasies about kindergarten age girls. After he fantasizes about a girl, he engages in voyeuristic activity such as watching the child undressing, showering, or going to the bathroom. The boy then steals the underwear of the girl he is targeting and masturbates into the underwear. After all of this, he grooms and sexually assaults the girl. In this hypothetical, one aspect of cognitive behavioral therapy might by to get the child to change his sexual fantasies in the hope that changing his thinking about sexual activity will eventually lead to a change in the child’s sexual behaviors. One aspect of relapse prevention might be to help the child recognize the very specific steps he takes before assaulting a child and help him rein in the behaviors when he sees warning signs. One aspect of MST might be to explore what is going on in the child’s family, school, and neighborhood that may influence his behavior and develop a plan for how these environments can play a role in improving the child’s conduct. If, for example, key players in the child’s life are aware of his voyeuristic tendencies, precautions will be taken to minimize possible opportunities. Although teachers and other professionals working with children cannot be expected to know the nuances of these various treatment options, they can advise parents to seek treatment that is supported by research. Youth workers can also reach out to experts in the field for guidance in working with a juvenile in school or another setting who has committed a sexual offense (see “Resources” section at the end of the chapter as well as the bibliography). When a juvenile has committed a serious offense and is being brought back into a school, church, or another setting, it is appropriate to have releases signed so that these professionals can discuss with the juvenile’s treatment team his or her risk for re-offense and what type of safety plan is warranted.

The Role of Schools in Addressing Problematic Sexual Behaviors When a child has engaged in problematic sexual behaviors, a school can play an important role in helping the child improve his or her behavior. Working with treatment providers and other professionals, a school can develop a behavior support plan that sets forth the expected behaviors of the child while in class, in the bathrooms, in the school yard, and at school functions. Equally important, the plan can establish the role of school personnel in helping the child achieve these expectations and letting the child know who he or she can speak with if they are having personal issues or questions about what is appropriate or inappropriate (Department of Education, South Australia 2013). If the victim is also attending the same school, there needs to be a safety plan to protect this child and any others who may be at risk. If the victim cannot be physically protected, or is emotionally unable to handle being in the same school with the offender, it may be appropriate to consider another school setting for the child with sexual behavior problems. A school should engage with professionals and parents in these cases even if the sexual assault or other problematic behaviors did not occur on school property.

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Needless to say, children victimized or engaging in problematic sexual behaviors may have additional challenges attending school. Whenever an outside event impacts a child’s ability to function in school, teachers and other professionals need to be aware of the situation and adapt accordingly.

The Risk of Re-offense Since recidivism is measured by whether or not an offender gets caught again, the actual rate of an adult or juvenile offender’s recidivism is always higher than the numbers reported by researchers. This is because, in all likelihood, some offenders commit additional offenses but do not get caught. Nonetheless, it is encouraging that juveniles who commit sexual offenses have relatively low rates of recidivism (7–13%). We also know from research conducted at 10 and 20 year intervals that juveniles who underwent some form of evidence-based treatment, had lower rates of recidivism than did juveniles who did not receive treatment (Worling et al. 2010; Worling and Curwen 2000). This is true whether recidivism was measured by another charge for a sexual offense, a nonsexual violent charge, or a charge for any offense at all (Worling et al. 2010; Worling and Curwen 2000). There are some factors that increase or decrease the risk a juvenile will commit another sexual offense. The following factors elevate the risk of recidivism: • Deviant sexual fantasies involving an interest in prepubescent children and/or sexual violence • Committing sex crimes despite prior charges or convictions • Multiple victims • Targeting strangers • Social isolation/unwillingness or inability to form peer relationships • Unwillingness/inability to participate in treatment (Ratnayake 2003) On the other hand, these factors are associated with a lower risk of recidivism: • • • • •

Positive family functioning Positive peer social groups Availability of supportive adults Commitment to school Pro-social, non-criminal attitudes (ATSA 2012)

Youth serving organizations such as the Boy Scouts, Girl Scouts, and Big Brothers/Big Sisters can help a child develop healthy adult relationships and positive peer groups, and by providing appropriate supervision. To the extent, a child’s personal history of trauma has played a role in sexual misconduct (Levenson et al. 2014), and developing a healthy spirituality can lower the effects of an abusive childhood (Reinert et al. 2016; Bryant-Davis et al. 2012; Walker et al. 2009).

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A Hypothetical Case Study on Risk Assessment John endured years of physical, sexual, and emotional abuse at the hands of his biological parents. His father was an alcoholic. His mother suffered from numerous mental health conditions and was hospitalized psychiatrically on several occasions. Eventually, when he was 10 years old, the parental rights of his parents were terminated and John was adopted by Robert and Kendall Smith, a married couple in their mid-30s who are unable to conceive children. Mr. Smith is a former mechanic who now owns a very successful car repair business. Mrs. Smith has a master’s degree in education and teaches special needs children at a local public school. Both Mr. and Mrs. Smith are very active in church and they intend to instill religious values in any children they raise. Sally, another adopted child in the Smith family, was born the same year as John in the very same town but to a different mother. Sally’s biological father is unknown. Sally is severely delayed and her biological mother is addicted to drugs, chronically depressed, and unable to address Sally’s needs. Although she tried to raise Sally for a number of years, the mother voluntarily terminated her parental rights when Sally was 10 years old and agreed to an adoption by Mr. and Mrs. Smith. From the age of 10 to the age of 13, John and Sally live with their adopted parents and form a strong bond to Mr. and Mrs. Smith and, to a lesser extent, with each other. As John approaches adolescence, he realizes Sally is his only friend. He is shy and awkward at school and often bullied. He notices his emerging attraction to girls but is unsure how to speak with them without being made fun of. He is frustrated, unsure about the changes in his body, and feeling sexually curious. One day, he asks Sally if she would like to play husband and wife, a game that eventually ends in John sexually penetrating his adopted sister with his fingers and penis. The game happens on two separate occasions in the next week until Sally tells her mother, who calls the authorities. A forensic interviewer speaks with Sally and it becomes very clear she lacks the capacity to consent and that John manipulated her into agreeing to sexual activity – promising her gifts and insisting she not tell “or else she would get into trouble.” When a police detective interviews John, he admits penetrating Sally but says he “just wanted to know what it felt like.” He says he understood his sister was delayed and that he “probably took advantage of her.” When asked if he used a condom to reduce the risk of pregnancy, John replied “gosh, that never occurred to me.” John is adjudicated delinquent and ordered into an out of home placement. He is also ordered to receive evidence-based treatment related to his sexual assaults. Sally also receives therapy for the assaults. After several months, John’s treatment provider reports he has made significant progress. John has learned about healthy and unhealthy fantasies, has grown his social skills, has a strong sense that what he did was wrong, and is not engaging in cognitive distortions or other excuses for his conduct. John is doing very well in school, reports enjoying Catechism classes at church, and does not have delinquent or other criminal desires. The treatment provider for John says he is at low risk to re-offend.

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Meanwhile, Sally’s treatment provider says that she, too, has progressed in treatment. According to her treatment provider, she has said that while she does not like what John did, she really misses him and wants to have her brother home. Eventually, the therapists agree to slowly integrate John and Sally into each other’s lives and allow them supervised interactions in the home of their adoptive parents. All parties report the visits went well. Applying the research to this hypothetical, John is likely at low risk to re-offend. He does not have deviant fantasies about violence or prepubescent children. Instead, he fantasized about children his age (though the child he focused on was mentally unable to consent). John did not target a stranger, does not have multiple victims, and does not have prior charges or adjudications. Although he has struggled with an inability to form friends his own age, his treatment provider reports meaningful progress on this issue. Perhaps most importantly, he has made progress with a treatment provider to address his sexual misconduct, and the treatment has involved an evidence based model. The fact that John’s adoptive parents provide a positive family structure, that he is committed to school, has a noncriminal attitude, and an emerging sense of spirituality are additional factors weighing in his favor. There is, however, no guarantee that John won’t re-offend. Accordingly, even if he is allowed to return home and live in the same house as his sister, there will need to be a solid safety plan. The issue of safety planning is considered below.

Re-uniting Siblings When There Has Been a Sexual Offense When a child commits a sexual offense against a brother or sister which results in a removal from the home, the issue of reunification is complex. At a minimum, the child committing the offense must have made meaningful progress in treatment as determined by the treatment provider (Bonner 2009). Assuming this threshold is met, an appropriate safety plan can be considered that includes the following elements: • • • • • • • •

Close supervision of the child committing the offense Prohibiting the child from babysitting or supervisory authority Prohibiting the child from bathing or dressing other children Requiring the child to be fully dressed in public areas of the home Prohibiting the child from accessing sexualized materials Prohibiting the child from sharing a room with younger children Prohibiting the child from going into other children’s rooms Prohibiting the child from hugs or kisses with the victim which, among other things, may bring back memories of the sexual assault • Prohibiting horseplay, wrestling or tickling with children (Bonner 2009) Even if the child who has committed the offense has progressed in treatment and a strong safety plan is in place, the needs of the victim must always come first. Accordingly, he or she must be able to emotionally handle the return of the offender to the home. If this is not the case, the offender should not return home and the

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offender’s parents and the professionals working with him or her can help the child understand that even with remorse and improved behavior there are consequences for our conduct and that putting the needs of those we have harmed first is a critical lesson to master.

Investigative Challenges in Responding to Problematic Sexual Behaviors of Children A multidisciplinary team (MDT) is a group or professionals that coordinates a response to a report of child abuse. The MDT typically includes law enforcement, child protective services, prosecutors, medical and mental health providers. When addressing the problematic sexual behaviors of children, particularly those who are adolescents and teens, the MDT may face at least three challenges. First, how should the MDT respond when a child is both a victim of child sexual abuse and a perpetrator? How will a child’s constitutional rights against selfincrimination be protected? Will there be separate interviews for the victimization and the offense? Second, how does an MDT respond when an adolescent or teenage victim is “compliant” in his her or her abuse? Third, how does an MDT respond to a situation in which there are multiple juvenile offenders involved in a sexual assault and one or more of these offenders was subjected to peer pressure? These challenges are considered below.

Investigative Challenges: Questioning Child Offenders When an MDT is investigating a juvenile alleged to have sexually assaulted another child, at least two unique challenges are present. First, if the child is old enough where it is possible he or she will be charged as a delinquent or even referenced to adult court, it is critical the interview with the offender be conducted by someone who understands child development and who speaks to the child in a way that lessens the risk any incriminating statements will be suppressed by a court because the child lacked the capacity to waive his or her constitutional rights. Factors courts look at include the age of the child, prior experiences with the law, the physical and mental condition at the time of questioning, the absence or presence of parents or other supportive adults, the length of the questioning, and other conditions during the questioning (Vieth 2001). When a law enforcement officer deems it appropriate to give a child a Miranda warning, it is critical the warning be given in a way a child can understand. One possibility is to read a right, such as “you have the right to remain silent” and then ask the child what that means to him or her. If the child articulates something to the effect “it means I don’t have to talk to you,” the officer can affirm that is correct. If the child cannot articulate the meaning of the right, the officer will need to spend more time speaking to a child in a manner he or she will understand. This is yet another reason why investigators should receive forensic interview training (Faller

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2015). Even if they do not routinely speak with child abuse victims, they frequently interview children alleged to have committed sexual or other delinquent acts. Second, when a juvenile is both an alleged offender and an alleged victim, the MDT must balance the need to protect the child victim with the need to hold the child accountable for any offenses he or she committed. This is particularly challenging when it is not known if a child is both a victim and an offender until one or more interviews commences. As a general rule, a child who is victimized should be interviewed in a Children’s Advocacy Center (Chandler 2006) by a forensic interviewer who meets national training and other standards for conducting the interview (National Children’s Alliance Standards 2017). If during the forensic interview a child abused by a parent begins to disclose that he or she has abused a sibling, it would be appropriate for the interviewer to stop the child and say something to the effect, “what you say is very important but there is someone else who will speak to you about what happened with your brother.” This is because the interviewer is probably not a detective and thus should not be giving Miranda warnings or otherwise addressing the subject of a child’s legal rights. Also, the child needs to be made aware of the difference between victimization and offending and that different systems and different parties may be involved in each. A child who has developed rapport with an interviewer may feel betrayed if they are told they are not in trouble for anything that happened to their body but no one clarifies they may be in trouble for sharing things they have done to the bodies of other children. If, though, the juvenile is very young and not at an age where he or she could legally be charged as a delinquent but will simply be the subject of a civil child protection matter (Russell 2014) where any sexual conduct is also viewed as product of the abuse itself, the MDT may make a decision to get all the facts out during the forensic interview. However, this is why it is important to have criminal prosecutors and civil child protection attorneys present or nearby to give legal advice. A different situation is present if a law enforcement officer is speaking with a child alleged to have committed a sexual assault and, during that interview, the child alleges he or she is a victim of sexual crimes at the hands of a parent or other adult. In that situation, it may be best to continue to receive the information and then, if necessary, have a CAC forensic interview completed at a later date. This is because stopping the child and scheduling a forensic interview may impair the investigator’s ability to keep the child safe. If, for example, the child is sent back home he or she may be violated again. Also, if an offender is tipped off the investigator is exploring this topic, he or she may destroy critical evidence or pressure a victim not to cooperate with the authorities.

Investigative Challenges: Compliant Victims A “compliant” victim is a term “sometimes used to describe those children who cooperate in or ‘consent’ to their sexual victimization. Because children cannot legally consent to having sex with adults, this compliance does not in any way

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alter the fact that they are victims of serious crimes” (Lanning 2005). Consider, for example, this hypothetical case, modified from an actual fact pattern. A 14-year-old girl develops a crush on a 25-year-old male school teacher. In addition to flirtatious behavior in class, she begins to leave him notes expressing her affection and indicating she is “available.” The teacher does not encourage this behavior and reports the child’s conduct to the principal. The school decides to place the child in another classroom. One day, the child steals her father’s car (she is not even old enough to have a license) as well as a ladder and drives to the teacher’s house. The teacher is renting an upstairs room from an elderly woman and, since it is late at night, everyone is asleep. The girl places the ladder against the house, climbs up to the teacher’s room, cuts open a screen window, and climbs into his bed. She kisses the teacher on the mouth and begins to fondle his penis. The teacher awakes with an erection and the girl says “do you want to do something kinky?” The teacher consents to the request and allows the girl to tie him to the bed and she then performs sexual acts on the man. Given the noise, the elderly woman wakes up, walks into the teacher’s room, and discovers the child engaged in a sexual act with the man. The police are called and the teacher confesses to multiple acts of penetration with the child but also says “she broke into my bedroom and got me aroused. Any man would have been tempted to consent under these circumstances.” Given the facts of this case, the MDT may feel uncomfortable with the victim and may be tempted to minimize her proactivity in her victimization. A forensic interviewer may ask “did he invite you to his house? Did he supply the handcuffs and other equipment to be tied up? Did he threaten you?” Eventually, the child may realize that the police do not like her version of the facts and may lie about some of the offender’s conduct and hers. If these lies are discovered by defense counsel, it will weaken the victim’s credibility at trial and subject the investigators or forensic interviewer to being attacked by defense counsel for engaging in suggestive, even coercive questioning of the victim. Instead, investigators need to take victims as they find them and simply discover the facts. If the case comes to trial, the prosecutor, working with the MDT, can explain why a victim may be proactive in his or her own abuse (Lanning 2005). Perhaps the child was already abused and her promiscuity reflects a history of trauma (Felitti and Anda 2010). Even if there is no easy explanation for the victim’s behavior, a prosecutor can still succeed by reminding jurors why children cannot consent. In voir dire, a prosecutor can ask the jurors “how many of you, when you think back to your teenage years, consider yourself lucky to be alive?” In closing argument, a prosecutor can remind the jury that a child’s brain is not fully developed even as a teenager and that youth often take risks without appreciating the short and long term dangers. This is why we prohibit adults from sexually touching a child even if the victim asks to be touched and is proactive in his or her own victimization. A more challenging situation arises if the compliant victim is proactive in his or her sexual abuse at the hands of another child. Assume, for example, the hypothetical of the 14-year-old girl breaking into a teacher’s bedroom and tying him up did not involve a

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25-year-old man, but rather a 17-year-old boy. Given the significant developmental differences between an adult and a child offender (Russell 2014), there may also need to be differences in how an MDT and a court system assesses culpability, treatment, and the appropriate consequences for these potentially very different offenders. Stated differently, a 25-year-old teacher almost certainly knows it is criminal to engage in sexual activity with a 14-year-old girl even if she is a compliant victim. However, a 17-year-old teenager may not have the same appreciation.

Investigative Challenges: Peer Pressure Child sexual assaults committed by other children are more likely to involve multiple offenders than child sexual assaults committed by adults. Specifically, 23.9% of sexual offenses committed by children involve multiple offenders, whereas only 13.5% of child sexual assaults committed by adults involve multiple offenders (Finkelhor et al. 2009). One possible reason for this difference is peer pressure. As teenagers, we may succumb to peer pressures we would never submit to as adults. For instance, teenagers may get a peer to drive on thin ice simply because the fear of being called “chicken” is greater than the fear of the car going under the water. Recall the anecdote earlier in this chapter in which three juveniles have been bullying a particular child. While on a swim meet, they break into the victim’s hotel room and hold him down while they tickle and otherwise humiliate the child. Then one of boys puts his testicles in the victim’s mouth while the other boys, still pinning the child to the floor, watch in silence. Assume the subsequent investigation reveals that the assault was the idea of one primary aggressor, the boy who put his testicles into the victim’s mouth. Assume also that the evidence shows the other boys did not know he was going to go this far and that they did not intervene for fear they themselves would later be bullied. If this is the case, there may be differences in terms of treatment and the level of penalties administered in juvenile court to each of the offenders. Simply stated, peer pressure is a much greater concern in cases involving juvenile offenders and needs to be fully explored by the MDT and taken into account by the court. The possibility of peer pressure and other factors is one of many reasons why registering juveniles as sex offenders is controversial (Russell 2014). Although some juvenile offenders, particularly those who are extremely violent, may need to be monitored indefinitely, placing other children on a public registry may subject them to bullying and deprive them of friendships and other support they need to avoid future offenses (Russell 2014).

Key Points • Although most children engage in sexualized behavior, this conduct is typically developmentally appropriate. • The American Academy of Pediatrics and the National Childhood Traumatic Stress Network have published free, online resources to assist caregivers and

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professionals in assessing developmentally appropriate and concerning sexual behaviors of children. Sexually concerning behaviors among adolescents and teenagers include attempts at exposing the genitals of others, sexually explicit conversations with younger children, sexually explicit threats, degrading self/others with sexual overtones, and conduct that, if committed by an adult, would be a crime. Cognitive behavioral therapy, relapse prevention, and multisystemic therapy have empirical research support. With appropriate treatment, the recidivism rate of juveniles with sexual behavior problems is relatively low. Adolescents with deviant sexual fantasies, who target strangers, who have multiple victims, and have committed sexual offenses despite prior charges are at higher risk to re-offend. Schools must work with probation officers, treatment providers, and other professionals in establishing polices for children with sexual behavior problems. When re-uniting siblings where there has been a sexual offense resulting in a removal from the home, a safety plan should include close supervision of the child committing the offense, a prohibition of sexualized material, a prohibition of bathing or dressing with other children, and a prohibition of babysitting or other supervisory roles with children. There are multiple investigative challenges in assessing a child with sexual behavior problems including the possibility the youth has committed a sexual offense and has been sexually abused or otherwise endured trauma.

Summary When MDTs access quality resources and expertise, they are more likely to respond effectively to children with sexual behavior problems. MDTs need to distinguish between appropriate and concerning sexual behavior for pre- and postadolescent children. Appropriate behaviors may need adult guidance, whereas concerning behaviors may warrant an assessment and consideration of civil child protection or juvenile delinquency petitions. Understanding the root causes of problematic sexual behaviors is critical in selecting the appropriate evidence-based treatment program. Even with quality treatment, MDTs may have difficulty in deciding when a juvenile may be reunited with a sibling who he or she has abused. In all cases, the needs of the victim must take precedent. When a child has committed a sexual offense and is also a victim, MDTs need to have clear boundaries on which professional is responding to which aspect of the case. The child needs to be aware of and why different professionals are engaged in his or her case. When a victim is “compliant,” investigators need to be well trained to understand this dynamic and be able to explain it to any potential trier of fact. MDTs must also be cognizant that peer pressure plays a greater role in juvenile sexual offenses than offenses committed by an adult. This possibility should be considered when selecting a treatment program and assessing risk of re-offense.

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Conclusion When Hagar’s child faced death in the desert, we are told that God “heard the boy crying” and intervened, staying “with the boy as he grew up” (Genesis 21:14–21). In applying this lesson to the sexual behaviors of children, professionals working with children who are sexually abused by siblings or other youth must make sure that the victims are protected and their needs fully met. Child protection professionals and treatment providers must also be with the children exhibiting sexual behavior problems or committing sexual assaults in the hope that they will be held accountable for their conduct, appropriately treated, and grow up to be healthy adults.

Resources American Academy of Pediatrics. The American Academy of Pediatrics has a chart and other resources to assist parents and professionals in understanding developmentally appropriate and inappropriate sexual behaviors. These resources can be accessed via this link: https://pediatrics.aappublications.org/content/124/3/992 National Center on the Sexual Behavior of Youth. The NCSBY is a program of the University of Oklahoma and has a wealth of practical information to assist families and professionals working with children with problematic sexual behaviors. This is a link to the NCSBY website: http://www.ncsby.org/ National Childhood Traumatic Stress Network. The NCTSN has prepared helpful information for parents and caregivers to aid them in understanding the sexual development of children. The information is available in multiple languages and can be accessed by following this link: https://www.nctsn.org/resources/sexualdevelopment-and-behavior-children-information-parents-and-caregivers

Cross-References ▶ Abuse of Youth in Residential Settings/Institutions ▶ Forensic Interviewing ▶ Sexual Abuse of Children ▶ Sibling Abuse of Other Children

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Cavanaugh, D. J., Pimental, A., & Prentky, R. (2008). A descriptive study of sexually abusive boys and girls – Externalizing behaviors. In B. K. Schwartz (Ed.), The sex offender: Offender evaluation and program strategies (Vol. VI, pp. 12-1–12-21). Kingston: Civic Research Institute. Chandler, N. (2006). Children’s advocacy centers: Making a difference one child at a time. Hamline Journal of Public Law & Policy, 28, 315–337. Faller, K. C. (2003). Understanding and assessing child sexual maltreatment (2nd ed., p. 182). Thousand Oaks: SAGE. Faller, K. C. (2015). Forty years of forensic interviewing of children suspected of sexual abuse, 1974–2014: Historical benchmarks. Social Sciences, 4, 34–65. Felitti, V. J., & Anda, R. F. (2010). The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behavior: Implications for healthcare. In R. A. Lanius, E. Vermeten, & C. Pain (Eds.), The impact of early life trauma on health and disease: The hidden epidemic (p. 77). Cambridge: Cambridge Medicine. Finkelhor, D., Omrod, R. K., & Turner, H. A. (2007). Poly-victimization: A neglected component in child victimization. Journal of Child Abuse & Neglect, 31, 7–26. Finkelhor, D., Ormrod, R., & Chaffin, M. (2009, December). Juveniles who commit sex offenses against minors. OJJDP Juvenile Justice Bulletin, 1–11. Friedrich, W. N. (1993). Sexual victimization and sexual behavior in children: A review of recent literature. Child Abuse & Neglect, 17, 59–66. Friedrich, W. N., Grambsch, P., Broughton, D., Kuipers, J., & Beilke, R. L. (1991). Normative sexual behavior in children. Pediatrics, 88, 456–464. Hunter, J. A., & Figueredo, A. J. (2000). The influence of personality and history of sexual victimization in the prediction of juvenile perpetrated child molestation. Behavior Modification, 24, 241–263. Johnson, T. C. (2015). Understanding children’s sexual behaviors: What’s natural and healthy, Safer Society, Brandon, MA. Kellogg, N. (2009). Clinical Report – The evaluation of sexual behaviors in children. Pediatrics 124, 992–998. Lanning, K. V. (2005). Acquaintance child molesters: A behavioral analysis. In S. W. Cooper, R. J. Estes, A. P. Giardino, N. D. Kellogg, & V. I. Vieth (Eds.), Medical, legal & social science aspects of child sexual exploitation (pp. 529–594). St. Louis: G.W. Medical Publishing. Letourneau, E. J., Henggeler, S. W., Borduin, C. M., Schewe, P., McCart, M. R., Chapman, J. E., & Saldana, L. (2009). Multisystemic therapy for juvenile sexual offenders: 1-year results from a randomized effectiveness trial. Journal of Family Psychology, 23, 89–102. Levenson, J. S., Willis, G. W., & Prescott, D. S. (2014). Adverse childhood experiences in the lives of male sex offenders: Implications for trauma-informed care. Sexual Abuse: A Journal of Research & Treatment, 1, 1–20. Miccio-Fonseca, L. C. (2019). MEGA♪: Empirical findings on the preternatural: Sexually violent and predatory sexually violent youth. Journal of Child & Adolescent Trauma, 12(4), 457–467. Myers, J. (2005). Myers on evidence in child, domestic and elder abuse cases (p. 383). New York: Aspen Publishers. National Center on the Sexual Behavior of Youth. (2019). http://www.ncsby.org/. Last visited 2 Sept 2019. National Child Traumatic Stress Network. (2019). Sexual development and behavior in children. http://nctsn.org/nctsn_assets/pdfs/caring/sexualdevelopmentandbehavior.pdf. Last visited 3 Sept 2019. National Children’s Alliance. (2017). Standards for Accredited Members, 3–63. https://www. nationalchildrensalliance.org/wp-content/uploads/2015/06/NCA-Standards-for-AccreditedMembers-2017.pdf. National Children’s Alliance. (2019). https://www.nationalchildrensalliance.org/. Last visited 5 Sept 2019. Ratnayake, A. (2003). Juvenile sex offenses: Finding justice. Update, 23(9), 1–2. Reinert, K. G., Campbell, J. C., Bandeen-Roche, K., Lee, J. W., & Szanton, S. (2016). The Role of Religious Involvement in the Relationship Between Early Trauma and Health Outcomes Among

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Adult Survivors. Journal of Child and Adolescent Trauma, 9, 231. https://doi.org/10.1007/ s40653-015-0067-7. Reitzel, L. R., & Carbonell, J. L. (2006). The effectiveness of sexual offender treatment for juveniles as measured by recidivism: A meta-analysis. Sexual Abuse: A Journal of Research and Treatment, 18, 401–421. Rosenzweig, J. (2012). The parent’s guide to talking about sex: A complete guide to raising (sexually) safe, smart, and healthy children (pp. 103–114). New York: Skyhorse Publishing. Russell, A. (2014). Multidisciplinary response to youth with sexual behavior problems. William Mitchell Law Review, 40(3), 1058–1082. Salter, A. (2018). Adolescent sex offenders. http://www.annasalter.com/annasalter/Slides.html. Last accessed 3 Sept 2019. Sex Offender Sentencing, Monitoring, Apprehending, Registering, and Tracking (SMART). (2019). Sex offender management assessment and planning initiative. https://www.smart.gov/ SOMAPI/index.html South Australia Department of for Education Child Development. (2013). Responding to problem sexual behaviour in children and young people: Guidelines for staff in education and care settings (pp. 7–46). Adelaide: Government of South Australia: Department for Education Child Development. Turner, H. A., Finkelhor, D., & Omrod, R. (2010). Poly-victimization in a national sample of children and youth. American Journal of Preventive Medicine, 38, 323–330. Vieth, V. I. (2001). When the child abuser is a child: Investigating, prosecuting and treating juvenile sex offenders in the new millennium. Hamline Law Review, 25, 47–78. Walker, D. F., Reid, H. W., O’Neill, T., & Brown, L. (2009). Changes in personal religion/ spirituality during and after childhood abuse: A review and synthesis. Psychological Trauma: Theory Research, Practice & Policy, 1, 130–145. Widom, C. S., & Massey, C. (2015). A prospective examination of whether childhood sexual abuse predicts subsequent sexual offending. JAMA Pediatrics, 169, e143357. Published online at: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2086458. Last accessed 3 Sept 2019. Wiehe, V. R. (1990). Abuse: Hidden phsycial, emotional, and sexual trauma (Vol. 55). Lexington: Lexington Books. Worling, J. R., & Curwen, T. (2000). Adolescent sexual offender recidivism: Success of specialized treatment and implications for risk prediction. Child Abuse & Neglect, 24, 965–982. Worling, J. R., Littlejohn, A., & Bookalam, D. (2010). 20-year prospective follow-up study of specialized treatment for adolescents who offended sexually. Behavioral Sciences & the Law, 28, 46–57.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sexual and Gender Minority Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appreciating Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Understanding the Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sexual and Gender Minority Youth at Increased Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Impact of Child Sexual Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Traumatic Sexualization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Betrayal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stigmatization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Powerlessness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Considerations for Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Respecting Sexual and Gender Minority Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conducting Forensic Interviews with LGBTQ+ Children and Youth . . . . . . . . . . . . . . . . . . . . . . Therapeutic Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix A: Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. A. Russell (*) Russell Consulting Specialists, LLC, Vancouver, WA, USA e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_207

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Abstract

This chapter will focus on building awareness of the context and experiences of sexual and gender minority victims of sexual violence and offer strategies for providing supportive services, victim advocacy, and forensic interviews in a meaningful and culturally sensitive manner. The chapter also examines the factors that place sexual and gender minority youth at greater risk for sexual victimization and the barriers to support and services that these youth may face following their abuse and trauma. The chapter then offers an opportunity to examine current practices and learn practical skills to improve responses to and for sexual and gender minority child and adolescent survivors of sexual violence. Keywords

Sexual and gender minority youth · LGBTQ+ · Child sexual abuse · Sexual violence · Intersectionality · Traumagenic model

“[C]ulture, even as it now talks about gays — and so presumably believes that gays exist somewhere — still acts upon a presumption that everyone is heterosexual. . ..” (Mohr 2005)

Introduction Mohr (2005) introduces us to what is called “The Heterosexual Presumption”; the idea that society assumes that the people with whom we come into contact are straight, until a particular reason calls attention to the person’s sexuality, such as a television program or a news story. This presumption comes with no need for conversation; it is mutually understood. Unfortunately, this “Heterosexual Presumption” is often an unrecognized bias and may lead to misunderstanding the experiences of sexual and gender minority children and youth, and consequently, inappropriate responses, and misdiagnoses and treatment planning for any sexual trauma that they may experience.

Sexual and Gender Minority Youth Appreciating Terminology Understanding the experiences of sexual and gender minority youth first requires an understanding of the language used among and about this population (Killermann 2019). Often referred to as the LGBTQ+ community, this population is incredibly diverse; much more than the commonly used acronym represents. Individuals who identify as lesbian, gay, bisexual, or transgender (LGBT) represent only a portion of those who are included in this “alphabet soup,” and much of the research conducted includes only individuals who identify as lesbian, gay, or bisexual. Acceptance and

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affirmation of the LGBTQ+ community includes using supportive and appropriate language (Killermann 2019). In addition to these introductory comments regarding language and concepts related to gender and sexual minority children and youth, an appendix to this chapter includes a list of terminology compiled from multiple sources to provide definitions and guidance for individuals working with this population. This list is not fully comprehensive, and as the sexual and gender minority culture changes across time, so too does the language of gender and sexuality. The LGBTQ+ community incorporates broad concepts and terminology. While some language may seem new to some professionals, it is critical that professionals recognize that the concepts of more than two genders and various sexual orientations have existed and been honored by indigenous societies for generations across the globe (Cruz 2018). Implicit biases should be confronted and addressed to better establish positive working relationships with LGBTQ+ youth, and their sexuality, orientation and identity should not be pathologized, nor their trauma and victimization dismissed without further investigation and understanding of their experiences. Furthermore, it is not enough to merely tolerate members of the LGBTQ+ community; instead, they should be accepted, included and affirmed. Use of inclusive language helps reassure children and youth served that professionals actually see them for who they are, and helps to provide an environment of safety, equity and respect (Killermann 2019). References in this chapter to sexual minority youth generally include those who identify as lesbian, gay and bisexual or pansexual (LGB, P), and sometimes queer or questioning (Q) (Reisner et al. 2015). References to gender minority youth generally comprise those who identify as queer or questioning (Q), or transgender (T) (Austin and Craig 2015). The term queer has, in the past, been used as a pejorative reference to the all-inclusive LGBTQ+ community; however, some community members, particularly those in younger generations, have reclaimed the term and co-opted it as their own, often using queer to identify all members of the LGBTQ+ community. This author will use a variety of terms to reference various members of the LGBTQ+ community throughout this chapter, including queer, sexual minority, and gender minority. Furthermore, this author will employ the use of “they” and “their” as a nonbinary, gender-neutral singular pronoun. Professionals who work with LGBTQ+ children and youth should become familiar with the sexual orientation, gender identity and gender expression, or SOGIE, for each child. This includes working with the child to understand their biological sex, or anatomy; their sexual orientation, or physical/sexual, romantic or emotional/spiritual attraction to others; their gender identity, or psychological sense of self; and their gender expression, presenting as male or female or gender-fluid, moving between the two traditional genders (Killermann 2019; see also Fig. 1).

Understanding the Challenges Up until recently, we have only had estimates of the number of children and youth who identified as sexual or gender minorities. However, with the inclusion of questions regarding sexual minority status in more recent Youth Risk Behavior

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Fig. 1 The Genderbread Person. (Reprinted with permission from https://www.itspronouncedme trosexual.com/downloads/Genderbread%20Person%20v4%20ALL.pdf)

Surveys (YRBS) conducted widely with high school students, which are weighted to match national population data, we now have information upon which professionals can rely. In the most recent Youth Risk Behavior Surveillance process, Kann et al.

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(2018) found that just over 85% of the youth identified as heterosexual nationally, nearly two and one-half percent identified as gay or lesbian, and 8% identified as bisexual. Those who were not sure of their sexual identity totaled just over 4% nationally (Kann et al. 2018). Families are an important source of support for children and youth; however, many queer youth do not have family members that support LGBTQ+ people, with less than 25% of youth stating that they are comfortable being out in their own homes, and nearly half reporting that their families do not make them feel accepted for being queer (HRC n.d.-a). Queer youth who are also racial minorities are reporting experiencing more negative comments about LGBTQ people than their white queer peers. Acceptance is not just an issue for LGBTQ+ youth in their homes. Many queer youth report feeling unsafe in the school environment, with a mere 26% indicating that they always feel safe in their classrooms. The rest report experiencing bullying, discrimination, and harassment, not just from peers, but also from teachers and other school staff, as well (HRC n.d.-a). Transgender and other gender minority youth report experiencing even greater verbal and physical harassment in schools than sexual minority (LGB) youth. They report that they are unable to use bathrooms and locker rooms of their gender identity and are frequently deadnamed, or called by the name of their sex assigned at birth rather than the name of their gender identity, and are referred to with inappropriate gender pronouns (HRC n.d.-b; Knutson et al. 2019).

Sexual and Gender Minority Youth at Increased Risk According to FBI Hate Crime Statistics (2012), 19.6% of hate crimes are motivated by sexual-orientation bias. Developing intimate and sexual relationships is a normative, age-typical task for adolescents (Mitchell et al. 2014), but coming out for youth, which typically begins during adolescence, also brings additional risk for harm. It is the job of an adolescent to begin to explore their identity and to gain their independence; however, poor familial relationships of gender and sexual identity youth may increase their search for external relationships. Due to high prevalence of rejection and stigmatization by their peers, queer youth often seek substitutes for peer relationships with older, and sometimes predatory, individuals. Normative adolescent experimentation regarding sexual orientation and identity opens queer youth up to abuse and exploitation, with queer youth more likely to seek out an older partner for sexual exploration when excluded and rebuffed by their straight and cisgender peers.

The Impact of Child Sexual Abuse In 1985, Finkelhor and Browne developed the Traumagenic Dynamics Model to provide information and context around the experiences children have with sexual victimization and to help professionals understand how this form of trauma impacts

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children emotionally and behaviorally. Finkelhor and Browne (1985) outlined four particular dynamics of child sexual abuse, including traumatic sexualization, betrayal, stigmatization, and powerlessness. In 1990, Wyatt incorporated aspects of intersectionality to Finkelhor and Browne’s model, looking at the four dynamics of sexual victimization through the lens of ethnic minorities. Wyatt (1990) proposed that the dynamics experienced by victims of child sexual abuse were compounded by their minority status. Here, we will discuss the impact of sexual victimization on sexual and gender minority youth, and how this intersectionality compounds and exacerbates the negative experiences of LGBTQIA+ youth who have been sexually abused.

Traumatic Sexualization Finkelhor and Browne (1985) explain that sexual abuse influences a child’s sexual development and their values and beliefs regarding sexuality, resulting in traumatic sexualization. When sexually abused, some children learn that their body is an instrument to fulfill normative physical and developmental needs such as food, clothing, housing, and love. Children may engage in developmentally inappropriate sexualized behaviors in their efforts to gain mastery of their victimization or understanding of their sexual identity. Children who have been sexually abused may experience confusion regarding sexuality and their sexual development and may fail to understand and display appropriate sexual and physical boundaries with others. These children may be overly physically affectionate with people, including those they may not know. In the alternative, some children associate sexual acts with negative emotions such as confusion, anger, and fear. These emotional associations with sexual activity may adversely impact their sexual experiences later in their lives. When we apply Finkelhor and Browne’s (1985) dynamic of traumatic sexualization to LGBTQ+ populations (adapted from Wyatt 1990), we can see how their experiences as both victims of sexual abuse and as sexual and gender minority youth are compounded. There are numerous stereotypes about the sexuality of queer youth in our society, including the perception that LGBTQ+ youth are more sexually active than straight youth (Cruz 2018). According to the most recent YRBS, just over 94% of youth nationally who only had sexual contact with a sex different than theirs identified as heterosexual; of those students who had sexual contact with someone of the same sex or with multiple sexes, about 20% identified as heterosexual; nearly 70% identified as gay, lesbian, or bisexual; and just over 11% were unsure of their sexual identity. Of those youth who had sexual contact before the age of 13%, 3% identified as heterosexual and just over 6% identified as gay, lesbian, or bisexual (Kann et al. 2018). This assumption of promiscuity, frequently applied to all queer youth, does not account for sexualized behaviors that may be exhibited by these youth as a result of their victimization. LGBTQ+ youth are at increased risk for victimization, and victimization complicates sexual development for youth. Kann et al. (2018) found almost 18% of LGB

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students experienced rape at some point in their lives, a rate more than three times that of straight students. When victimized, queer children and youth may become much more confused about their sexual and gender identity. For example, a sexual minority child may become confused about their sexual identity if they experience physical pleasure from their victimization by someone of a different sex. Sexual offenders may then further complicate the issue by using the child’s arousal to shame the victim for their response or to inculpate the child due to their physical reaction. Gender minority youth may face challenges with their body image, fearing that they were victimized because they appeared too “feminine” or “masculine.” These victims may have complicated reactions regarding their perceptions of masculinity and femininity, which may move them to present themselves in a manner different than their gender identity.

Betrayal An estimated 92% of children and youth who experience abuse are victims of a parent or caregiver (USDHHS 2020); nearly 93% of child sexual abuse is perpetrated by a family member or acquaintance (USDOJ 2000). Children are likely to have a difficult time processing their victimization when their abuse is at the hands of someone with whom they have a close emotional attachment, or someone upon whom the child depends for food, shelter, love and affection (Finkelhor and Browne 1985). These youth are further manipulated by their offenders through methods of grooming, control, and dishonesty. When betrayed by someone on whom the child believed they could depend, it is not unusual for them to experience mistrust of others with whom they have relationships later in their adolescence and adulthood. This sense of betrayal victims of sexual abuse experience is not just at the hands of the individual who perpetrated their abuse (Finkelhor and Browne 1985). Children may also feel as if they were betrayed by the nonoffending caregiver, as well, whom they may believe knew or should have known about their abuse and failed to protect them from victimization. Family members who attempt to manipulate victims to retract their reports of victimization may also be a source of betrayal, as well as those family members who shame, blame, or ostracize children following their victimization. Children and youth may also feel betrayed by the very systems that respond to their allegations of sexual abuse: child welfare systems that may remove the child from the home instead of the offender; law enforcement officials who may not believe sexual abuse allegations; criminal justice systems that fail to hold offenders accountable; or even a criminal justice or child welfare system that, in the child’s mind, tears the family apart. Children may also feel betrayed by their own bodies if the sexual contact feels good, even if unwanted. Systemic betrayal of sexual and gender minority youth is apparent in elementary, middle, and high schools; the child welfare system; and juvenile detention facilities. According to the US Transgender Survey (USTS), children and youth who were “out” or perceived as transgender in school report experiencing verbal harassment

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(54%), physical assaults (24%) and sexual assaults (13%) (James et al. 2016). Twenty percent of these respondents believe they experienced harsher school discipline because teachers or staff thought they were transgender, and 17% of responding individuals left school before graduation due to the severe mistreatment that they experienced as a result of their perceived sexual orientation or gender identity (James et al. 2016). Sexual and gender minority youth are overrepresented in the child welfare system, with many of these youth running away or being removed from their families as a result of their sexual orientation, gender identity or expression. A meta-analysis found that LGBTQ+ youth make up a higher proportion of youth in foster care than of youth not in foster care (AECF 2016). Just over a quarter of LGBTQ+ youth in foster care were removed from their families of origin due to parental conflict regarding their SOGIE, and nearly one-third experienced physical abuse by a family member after coming out (ACAF n.d.). An estimated 13 to 15% of youth in the juvenile justice system identify as LGBTQ+, two to three times the prevalence of LGBTQ+ youth in the overall youth population (Majd et al. 2009). The USTS found that 20% of respondents who had been held in jail, prison, or juvenile detention in the past 12 months were sexually assaulted by facility staff or other inmates during their incarceration (James et al. 2016). As we see more and more queer characters portrayed in film and television shows, and more professional athletes and public personalities and officials come out, there may be a perception that it is somehow now easier to be queer than in decades past. However, queer children and youth are exposed on a regular basis to the discrimination and intolerance that the LGBTQ+ communities continue to experience (adapted from Wyatt 1990; James et al. 2016). The institution of marriage was not an option for same-sex couples until 2015, when the US Supreme Court ruled marriage for same-sex couples legal in all 50 states (Obergefell v. Hodges, 135 S. Ct. 2071, 2015). Even now, same-sex couples may face discrimination when planning their nuptials, with businesses such as bakeries able legally to decline to serve them. LGBTQ+ prospective adoptive and foster parents also continue to face discrimination in their attempts to care for children; access to appropriate medical care is not always available, particularly for transgender individuals (James et al. 2016), and applications for housing and employment by individuals in the LGBTQ+ community are still rejected, even if unlawfully. Faced with this reality of intolerance, queer children soon learn that the world around them is not always a good or safe place for them to be. When adults overlook a child’s concerns about unfair or hurtful treatment they experience due to the child’s sexual orientation, gender identity, or sexual expression, it sends a message that their feelings are not important, and that they are not valued as individuals. Children may feel betrayed and disappointed by the lack of response they receive from parents and other adults, and learn that adults are not available to them to ward off harm or protect them from traumatic experiences. Differences in how LGBTQ+ populations are treated are apparent not just in the “adult” world. These differences are apparent within families as well. The incidence

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of victimization in families increases when a child is of sexual minority status. In one study comparing lesbians and their straight siblings, Alvy et al. (2013) found that 20.4% of the lesbians studied reported experiencing physical abuse by their parents or caretakers, compared to 10% of their straight sisters. The researcher additionally found that while 26.6% of the study’s lesbians reported experiencing child sexual abuse, 15.7% of their straight sisters reported experiencing it (Alvy et al. 2013). These child victims may feel betrayed for being “different” by not only the offending parent or caretaker, but by their nonabused siblings and by themselves as well. James et al. (2016) found that 8% of individuals who responded to the US Transgender Survey (USTS) and were out to their immediate family with whom they lived were kicked out of their house. The researchers further found that these youth were three times more likely to have been engaged in sex work in their lives than those who were not expelled from their family house (James et al. 2016). Betrayal due to being “different” is also evident in queer children’s experiences with incidents of bullying, assault, derogatory name-calling and exclusion from activities, groups, and clubs by their peers (adapted from Wyatt 1990; see ▶ Chap. 47, “Bullying and Cyberbullying Throughout Adolescence”). One respondent to the USTS provided the following statement, “I was constantly bullied and physically assaulted by my classmates. Teachers would often see it happen and make no move to intervene. The harassment continued, and I eventually had to change high schools three times, each time just as bad as the last, until I finally gave up on public schools” (James et al. 2016, p. 134). Mitchell et al. (2014) found that, as compared to 32% of straight youth, 71% of middle school and high school LGBTQ+ students reported sexual harassment in the last year. The study further found that youth who are transgender are more likely than lesbian, gay, or bisexual youth to be sexually harassed by their peers (Mitchell et al. 2014). Kann et al. (2018) found that LGB youth were bullied online and on school property at twice the rate of straight students and were more than twice as likely to stay home from school to avoid violence they feared experiencing on their way to or on school grounds. Some individuals in queer communities may also feel betrayed by religious entities, churches, or even G-d (Note: the author follows Messianic Jewish and Jewish traditions to avoid the erasure or defacement of the Name of G-d, based in Deut 12:3–4. The Name of G-d should be treated with respect, and in this chapter, the Name is not fully written to avoid disrespect, defacing or erasing the Name.). Individuals in sexual and gender minority communities report religious intolerance, with nearly one in five individuals who were out or perceived as transgender abandoning their spiritual or religious communities due to feelings of rejection from the religious community (James et al. 2016). They additionally cite incidents when they were victimized and sought help and support, but were blamed for their victimization because of their sexual orientation, gender identity, or sexual expression. Queer youth who seek support and acceptance from leaders in spiritual or religious communities may become targeted as victims by leaders who manipulate their victims and abuse their positions of authority. While some victims of child sexual abuse and assault may turn to religion and spirituality for understanding and peace, other victims may lose their faith in a G-d that they

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believe abandoned them, “allowed” the abuse to happen, or even “targeted” them for abuse (Russell 2018).

Stigmatization By its very nature, child sexual abuse is a secret. The offender pressures the victim to maintain their silence; members of our society, in their reticence to speak openly of sexuality and sexual development, convey shame and guilt upon the victim for “engaging” in sexual encounters (Finkelhor and Browne 1985). The topic of sexual abuse is taboo, and those who are victims are frequently perceived to be as “deviant” as those who offend. Victims who receive these messages regarding secrecy from their offender or society incorporate the associated negative connotations regarding their victimization into their own self-image. Unfortunately, they also may receive explicit messages from their offender, family members, church communities, and others, indicating they are damaged, that they were somehow complicit in their own victimization, or that they are now “unclean” or perceived to have loose morals. Some of these young victims, in their attempts to self-medicate, may engage in alcohol and drug use or other risky behaviors. Some child and adolescent victims may feel isolated from their support systems and seek comfort, affection, and validation from inappropriate sources and may thereby get involved in criminal activities or be lured or forced into prostitution. Wyatt (1990) posited that ethnic minorities experience stigmatization because of their culture or race, and that as a result of the intersectionality of their minority status and their sexual victimization, their experiences of stigmatization may be compounded. This is analogous to experiences of sexual and gender minority children and youth (NCTSN 2014). Regardless of a child’s sexual or gender identity, or where they are in the process of development of their sexual and gender identity or expression, victims of abuse by same-sex offenders are often labeled pejoratively as “gay” or “queer,” especially males. As discussed previously, queer youth often internalize feelings of being “less than” or “different” as a result of their sexual or gender identification or expression, even before they experience sexual assault. How queer youth experience and respond to their sexual victimization may be impacted by where they were in their development and understanding of their sexual orientation, gender identity, and expression at the time of the abuse, resulting in dual stigmatization (NCTSN 2014). Feelings of stigmatization, discrimination, and isolation are greater for LGBTQ+ youth of color due to the multiple layers of intolerance they experience (HRC 2018). Queer youth often suffer from low self-esteem and depression and experience social and emotional isolation from others (Kann et al. 2018). Queer youth also experience a higher incidence of suicidal ideation and suicide than straight youth and engage more frequently in self-medicating and self-harm (Kann et al. 2018; O’Brien et al. 2016; Reisner et al. 2015). When sexually victimized, the emotional challenges and social stigmatization queer youth face are exponential. The perceived link between sexual orientation and abusers is often parroted to them, and

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some sexually victimized youth are actually told that they are at risk of becoming offenders because they are queer. For youth who are out, their experiences with parental support in coming out may predict their willingness to disclose an abuse experience (Saltzburg 2004). Youth who were not supported by their parents or caregivers in their coming-out process may be more likely than their supported peers to internalize stigma associated with being queer and consequently be less likely to disclose sexual victimization or exploitation.

Powerlessness Finkelhor and Browne (1985) explain that child victims of sexual abuse are powerless against their abusers. Children are taught to be submissive to parents, caregivers, and other authority figures, and child sexual abuse offenders utilize that message to manipulate and control their victims and violate their bodies (▶ Chap. 35, “Adult Sex Offenders Against Children: Etiology, Typologies, Investigation, Treatment, Monitoring, and Recidivism”). The child loses agency over their body and their wants and needs are ignored. The abuser may employ various threats and physical force to gain compliance, intensifying the child’s feelings of powerlessness. If the abuser is the child’s parent or caregiver, the child’s dependence upon their abuser exacerbates the child’s loss of control over their body (Finkelhor and Browne 1985). Children’s feelings of powerlessness due to their abuse are reinforced when they are unable to tell others about their victimization or make people believe their outcries, or when they report their abuse and the abuse is permitted to continue. Child and adolescent victims who experience this loss of control over their bodies and the events around them may begin to feel helpless to control any of their interactions with others and are at increased risk to be victimized again throughout their childhood and adulthood. Children and youth whose sexual orientation, gender identity, and gender expression (SOGIE) are not straight and cisgender may be forced into conversion therapy or treatment programs to “fix” their “illness,” by parents and caretakers who render them helpless to find their own identity and be themselves. Some individuals have also expressed frustration and grief over their lack of input when sex and gender assignments were made for them at birth or as young children. James et al. (2016) found that nearly one-third (32%) of respondents of the US Transgender Survey indicated that they felt that the sex indicated on their original birth certificate was “different” than their gender at age 5 years or younger, and another 28% reported feeling different between the ages of six and 10 years. Children and youth may experience helplessness and hopelessness when the people around them do not understand or provide support for their individual identity, orientation, or expression, with 60% of LGB youth reporting feeling “sad or hopeless,” a rate twice that of their straight peers (Kann et al. 2018). This may be particularly true for transgender children and youth who have changed their birth names and gender to match their gender identity or gender transition. Transgender children and youth frequently experience deadnaming and

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misgendering, which violates their sense of self (HRC n.d.-b; Knutson et al. 2019). Deadnaming occurs when individuals refer to transgender children and youth by their birth name after they have changed their name to reflect their gender identity or transition. Misgendering occurs when transgender children and youth continue to be labeled with their sex assigned at birth, as opposed to their gender identity or transitioned gender. This may occur more often in the criminal justice system and the legal arena, and possibly school environment, than other social milieu when birth records, identification cards, and other legal documents reflect birth information of the child. This lack of sensitivity to the identity of the children and youth may further perpetuate their feelings of powerlessness over themselves and their bodies. Children and youth may witness the discrimination and intolerance experienced by LGBTQ+ adults, and as a result, vicariously experience the powerlessness of the adults to change oppressive people and systems they encounter (adapted from Wyatt 1990; Levounis et al. 2012). These feelings of powerlessness may be intensified for LGBTQ+ victims of sexual assault who are also African American or Latinx, placing them in what could be considered a “triple minority” status (Alvy et al. 2013). LGBTQ+ populations may also experience a sense of powerlessness due to a lack of self-representation in the media and in the entertainment and professional sports industries. While there has been an increase in the visibility of LGBT+ characters on television and in the movies, and members of professional sports, this occurrence has been so infrequent that it becomes a story in and of itself. As an example, one need only look at a piece published online by Outsports in December 2013 declaring 2013 as “the year of the out athlete.” The piece declared, “From high school coaches to professional athletes to sportswriters, 2013 saw the most-ever stories on publicly out people in sports” (“77 People,” 2013). LGBTQ+ individuals often lack heroes and positive role models from sexual and gender minorities, and up until recently, media representations of queer people were often outrageous stereotypes and caricatures. Similarly, victims of child sexual abuse are marginally covered in the media and are rarely represented in a positive and empowering manner. Mejia et al. (2012) found that, in spite of more than 63,000 substantiated cases of child sexual abuse in 2010, newspaper coverage of the topic averaged less than one story a week. Dorfman et al. (2012) found that in the first 9 days of media stories following the indictment of Jerry Sandusky, a mere 13% of the coverage focused on child sexual abuse, while 75% discussed Joe Paterno and other Penn State officials, the case itself or Penn State and its students and alumni. Nearly 8% of the newspaper coverage of the case against Sandusky made no reference to child sexual abuse at all (Dorfman et al. 2012), exemplifying the silence and powerlessness that envelops its victims. Berkley Media Group conducted several studies on media coverage of sexual violence and child sexual abuse (Dorfman et al. 2011; Mejia et al. 2012; Mejia et al. 2015). These studies consistently demonstrated that coverage of victims and their experiences was minimal, with the focus of these media stories most commonly on the criminal justice system or specific criminal trials (Dorfman et al. 2011; Mejia et al. 2012; Mejia et al. 2015). News coverage rarely focused on the resiliency or healing of victims, or of victims overcoming their assault experiences (Mejia et al. 2015). A notable recent exception regarding coverage of victims of child sexual

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abuse is the reporting on those abused by serial child sexual abuse offender Larry Nassar, USA Gymnastics national team doctor and osteopathic physician at Michigan State University. With over 200 victims providing victim impact statements at his sentencing, media coverage of victims in this case was extensive (see, e.g., Cacciola and Mather 2018; Moghe and del Valle 2018; Rahal and Kozlowski 2018). LGBTQ+ victims may experience feelings of powerlessness as a result of their victimization when they perceive that they were targeted for sexual abuse due to their sexual orientation, gender identity or gender expression. Alvy et al. (2013) found that, when compared to heterosexual women, bisexual and lesbian women were more likely to report childhood unwanted and forced sexual contact, as well as physical abuse and neglect. They also experienced more severe forms of child sexual abuse and significantly more incidents of victimization than their straight counterparts. The researchers also found that bisexual women and lesbians who reported presenting as gender atypical as children were more likely than cisgender girls to experience emotional maltreatment. In this comparison study, Alvy et al. (2013) further found that bisexual women and lesbians were more likely to report being revictimized in their teen years than straight women. Also, their early self-identification and coming out as a sexual minority was correlated with increased victimization over their lifetime.

Considerations for Professionals Respecting Sexual and Gender Minority Youth When working with children and youth from the LGBTQ+ community, it is important to demonstrate respect for them and to avoid making assumptions about their sex, gender, orientation or identity (Cruz 2018; Leach 2002). Professionals need to be informed about the multiple challenges, biases, and incidences of discrimination this population faces and overcome implicit biases that they may harbor about the LGBTQ+ community. A safe and affirming environment is critical to establish rapport and to engage the youth. This includes adopting and clarifying the language the youth uses. Children and youth may use terms and make references to aspects of their gender and identity that are unfamiliar to professionals; consequently, it is important that professionals not make assumptions about the meaning of the language youth use. Professionals may also inaccurately ascribe gendered pronouns to these youth and should inquire what pronouns the youth prefers. This can be addressed when professionals introduce themselves and their jobs by incorporating their gender preferences and asking the youth about their preferred name and their gender pronouns (Cruz 2018; Leach 2002). Not all queer youth are out, a term referring to their acceptance of their gender identity and willingness to share it with others. If a queer child or youth comes out to a professional, this should be acknowledged as a demonstration of trust on the part of the child. Professionals are encouraged to show interest in this one dimension of many of the child, and explore whether this information is something that the child

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has shared with others. Professionals should avoid assuming that the child is out to everyone if the child shares their SOGIE in a meeting with the professional. Professionals are also encouraged to ask the child what type of support they may need regarding this disclosure. Demonstrating acceptance of and affirmation for sexual and gender minority children includes more than interpersonal interactions. It also includes the physical space in which we interact (NCTSN 2014). Agencies and individuals who serve sexual and gender minority youth can demonstrate that the space into which they invite these youth is welcoming to all. They could post safe zone signs, display magazines and pamphlets that represent all types of cultures, including LGBTQ+ populations, and design paperwork and forms to be inclusive. This includes intake forms that avoid binary gender options for clients and those that provide options for identifying parents and caregivers, not mothers and fathers. Schools and youth-serving organizations are also encouraged to provide regular LGBTQ+ training to volunteer and paid personnel. The training should promote acceptance and inclusiveness, and educate personnel on implicit biases and both macroaggressions and microaggressions targeted at queer youth. Caretakers and family members should be provided opportunities to learn more about issues that impact queer youth, and should be taught to watch for signs of bullying, isolation, discrimination, and intolerance. Schools and agencies can also advise caretakers and family members to watch for changes in a queer child’s or youth’s behaviors and emotions, which may be indicative of maltreatment by peers or others. Mental health and medical professionals should be prepared to discuss LGBTQ+ issues with all children and youth, regardless of their SOGIE. Sexual and gender minority youth, and trans youth in particular, experience disparity when it comes to receiving competent medical, mental and behavioral health services. Due to the higher incidence of suicidal ideation, suicide attempts, and self-harm in queer youth than their straight peers, mental health and medical professionals should consider actively inquiring about suicidality of their patients when exploring other aspects of their health (Vargas et al. 2019).

Conducting Forensic Interviews with LGBTQ+ Children and Youth It is important that any forensic interview about suspected abuse or violence conducted with a child be with a professional who is trained in and employs a recognized forensic interview protocol (see ▶ Chap. 65, “Forensic Interviewing”). The interviewer should also be familiar with linguistics, child development, cultural issues, child abuse dynamics, legal issues, elements of the crime for which the child is being interviewed, and memory and suggestibility (NCA 2017; Newlin et al. 2015). The forensic interview, by definition, should be conducted as a part of a multidisciplinary team (MDT) investigation, in coordination with law enforcement, child protective services, if warranted, victim advocates, legal professionals, and medical and mental health professionals, as appropriate (APSAC 2012; Farrell and Vieth in press; Newlin et al. 2015; NCA 2017).

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While the names and number of the phases of the interview process and certain techniques employed may vary based upon the particular interview protocol, the basic phases are consistent across all protocols: interview preparation, rapportbuilding and orienting the child to the interview process, narrative event practice, transition to the topic of concern, detail-gathering regarding the abuse or crime if disclosed, and closure (APSAC 2012; Newlin et al. 2015). Following the interview, consultation with various team members should occur, to ensure the child and family receive referrals to medical, mental health, and social services, as needed. Prior to conducting a forensic interview with a sexual or gender minority child or youth, it may be helpful to briefly consult with the child’s parent or caregiver, or have an observing multidisciplinary team member do so. This is particularly helpful if the child is transgender or is gender-fluid. If the parent or caregiver is aware of the child’s sexual orientation, gender identity, and expression, it could prove helpful for the interviewer to understand how the child perceives themselves and presents to others. If the child is transgender or has experienced gender assignment, it is also helpful for the interviewer to be aware of that prior to speaking with the child. This will help the interviewer better understand the child’s experiences and consider how they may impact the child’s willingness and ability to talk about their victimization and trauma. As part of the rapport-building process, the interviewer should ask about the child’s preferred name, and when appropriate, their gender and pronouns. It is important that the interviewer, and observing team members, understand that a child’s identification as male or female may be fluid and may change during the course of their victimization. Assumptions about the child’s identity and gender should be avoided; it is not the role of the interviewer to ascribe names or gender for the child. While only a minority of cases proceed to trial in the criminal justice system, it may be beneficial for prosecutors to employ the use of expert witnesses to explain gender identity and fluidity to the judge or jury, who may not have much understanding of, or may have implicit biases about, LGBTQ+ children and youth. Some forensic interview protocols utilize anatomical diagrams to introduce the topic of concern when an open invitation, such as “What are you here to talk about today/ what do you know about being here today?” fails with a child (Farrell and Vieth in press; Gundersen 2016; Newlin et al. 2015). It is important to preface presentation of anatomical diagrams to children with an explanation of how they will be used. Interviewers may need to modify this preface when using these diagrams with children who are transgender, gender-fluid, or have experienced gender assignment. In these situations, interviewers are encouraged to avoid saying about the diagrams “one is a boy and one is a girl,” or asking the child, “Are you a boy or a girl?” when identifying body parts. In the alternative, interviewers are encouraged to introduce the diagrams in a slightly modified way: “I have two drawings. I use these drawings when I talk to kids. Different people have different names for body parts, and I want to know what words you use.” After naming the body parts on both the boy and girl diagrams, the interviewer can inquire of the child, “Do you have parts like this? . . . or this?” gesturing to both diagrams, and can further inquire, “Do you know someone who has parts like this?” Identification of the diagrams by gender

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may serve to confuse the child, and may bias the child to identify with a diagram that does not have the genitalia of the gender with which the child identifies. Interviewers should be aware that, even if the child identifies with and declares that they have different genitalia than what the interviewer may know or assume, or the child elects not to identify a gender that matches their own, the child can still be a credible reporter of their victimization or trauma experiences. The child may be able to move forward with the interview, and the interviewer or child may later utilize the diagrams for clarification purposes if victimization is disclosed. Gender-neutral diagrams or gingerbread-shaped diagrams are not recommended for use in forensic interviews (Russell 2008). If the allegation is related to sexual abuse, it is critical that information regarding sexual contact or exposure is clear regarding the specific body parts involved. If using diagrams to understand the child’s names for body parts, or to help facilitate or clarify disclosures, it is recommended that they have features of human bodies. This helps enable children and youth to recognize that the diagram is intended to symbolize the human body. Some protocols promote the utilization of anatomical dolls in forensic interviews as a demonstration aid for the child to use after a disclosure of abuse is made (Hlavka et al. 2010; Farrell and Vieth in press; Gundersen 2016). This technique is accepted only when the forensic interviewer is trained in the use of anatomical dolls and only postdisclosure in the forensic interview. Children should be provided guidance on using the anatomical dolls, including instruction that they are not toys and not for play or pretend. Furthermore, children should never to be forced to use the dolls to demonstrate or clarify their experiences. When introducing anatomical dolls for demonstration or clarification purposes, the use of gender and pronouns with the child is not necessary. Anatomical dolls can be introduced not as a “boy doll” or “girl doll,” but instead more generally: “When I talk to kids I sometimes use dolls with body parts.” In accordance with established forensic interview training regarding anatomical dolls, the child is shown the body parts on the doll that has genitalia consistent with the child’s report after the interviewer introduces the doll to the child. Depending on the child’s age, the interviewer may review the child’s names for the body parts on the anatomical doll. The doll is then presented to the child fully clothed, and the child is asked to use the doll to “show what happened” (Hlavka et al. 2010). At some point during the forensic interview, often between the transition to the topic of concern and the closure phases of the interview, interviewers are encouraged to assess for multiple forms of victimization and violence the child may have experienced, beyond the initial suspected form of abuse (Farrell and Vieth in press). Many children have experienced polyvictimization, or more than one type of abuse; this is particularly true for sexual and gender minority youth (Sterzing et al. 2017). Research demonstrates that children who are exposed to one type of abuse or victimization are at much greater risk for experiencing additional violence than those who were not exposed to abuse or violence. Finkelhor and colleagues found that more than two-thirds of youth who reported any type of direct abuse or victimization also reported additional types of abuse (Finkelhor et al. 2009; Finkelhor et al. 2011). When examining specific types of victimization, Finkelhor and colleagues found that

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half of sexually abused youth are abused in other ways, and if a youth reported being physically assaulted in the last year, they were five times more likely to be neglected or maltreated than those who had not experienced abuse, and six times more likely to be sexually assaulted than nonmaltreated youth. Cyr et al. (2012) conducted a study with a sample of youth involved in the child welfare system and cautioned that child protection professionals who target only one form of victimization fail to protect children and meet the specific service needs of maltreated children. The study found that 93% of the youth who were directly or indirectly victimized in the past year experienced more than one form of victimization, and 54% experienced at least four forms of victimization in the past year (Cyr et al. 2012). Another study (Mitchell et al. 2011) found a co-occurrence between online and offline victimization. Mitchell et al. (2011) found that 96% of children who reported being victimized online also reported experiencing offline victimization. Online victimization was most closely correlated with sexual harassment, rape, attempted assault, assault by a peer or sibling, witnessing an assault with a weapon, being flashed and being emotional abuse. Following a forensic interview regarding victimization, it is critical that sexual and gender minority youth receive appropriate referrals for ongoing support, victim advocacy, and mental health services to professionals experienced in working with this population. LGBTQ+ youth are more likely than straight youth to personalize their victimization and attribute their experience to their sexual orientation or gender identity or expression, as opposed to other external reasons (Mitchell et al. 2014). Support and therapy for the child or youth’s parent or caregiver is also critical, to ensure the child receives the family support they need following their victimization. The support of adults around them and feelings of connections to family are associated with lower levels of risk for problems with behavioral and mental health, suicidal ideation, and victimization (Mitchell et al. 2014).

Therapeutic Interventions Therapy services for sexual and gender minority youth who have been sexually abused should be provided by clinicians with experience working with this population. These youth may be experiencing intense feelings of betrayal, guilt, shame, rejection, and confusion regarding their identity, and whether their identification or appearance as LGBTQ+ was the cause of their victimization. LGBTQ+ youth who have been sexually victimized may not have come out or may have been outed as a result of their victimization (NCTSN 2014). Not only must the clinician address the trauma of the sexual assault and what impact that may have regarding the child’s identity, but clinicians should also be prepared to work with the child on understanding their sexual orientation, gender identity, and expression as a separate issue and what impact the sexual trauma may have on their SOGIE. Clinicians should also be prepared to directly address confidentiality issues that youth may have if they have not come out to their parents. Youths’ concerns about

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confidentiality may be a major barrier in building a safe and supportive relationship with them. Clinicians should also be prepared to work with the parents and caregivers of LGBTQ+ victims of sexual assault on the grief and self-blame they may experience regarding the child’s victimization. Clinicians may also need to address some of the stereotypes and biases parents and caregivers may hold regarding sexual orientation and identity of their child if the parents or caregivers are not familiar with the LGBTQ+ community (NCTSN 2014). Clinicians should also be aware of misconceptions that parents or caregivers may have regarding the purpose of treatment. Sexual orientation and gender identity is not a diagnosis requiring treatment, and clinicians may need to provide education and information to parents about treatment goals, as well as ineffective treatment modalities. Conversion, reorientation, or reparative therapy is not an accepted form of treatment and has been banned in a number of states due to its harmful impact on children and youth (Anton 2010).

Summary and Conclusion Effective interventions with sexual and gender minority children and youth who have been sexually victimized and exploited require more than a basic understanding of how sexual abuse impacts children and families. It also requires professionals to recognize that children’s trauma impact may be compounded by their sexual orientation, gender identity and expression. The complexities of trauma occur as a result of the accumulated intersections of personal identity, life experiences, and confrontation with oppression and rejection. Additional vulnerabilities, such as physical or intellectual disabilities, poverty, racial/ethnic minority status, and immigrant status, can further challenge recovery from sexual victimization. Professionals are encouraged to serve as allies for sexual and gender minority youth, seeking to understand, hear, and ensure safety for this vulnerable population. Fred Rogers is quoted as saying, “There is something of yourself that you leave at every meeting with another person.” The portion of themselves that professionals leave with the children and youth with whom they work should be acceptance and affirmation.

Key Points • Effective interventions with sexual and gender minority youth require an understanding of each individual’s sexual orientation, gender identity, and expression (SOGIE). • Demonstrate respect and acceptance for the child by using their preferred name and their gender pronouns. • Language is important: clarify and adopt the language the youth uses regarding their SOGIE. • Sexual and gender minority youth are at increased risk for experiencing sexual violence.

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• The trauma impact from sexual victimization on LGBTQ+ children and youth may be compounded by their sexual orientation, gender identity, and expression. • Organizations should demonstrate acceptance of and affirmation for sexual and gender minority children in the physical space where services are provided. This includes providing inclusive literature and forms.

Resources • • • • • •

Gay & Lesbian Alliance Against Defamation (GLAAD): www.glaad.org Gay, Lesbian, and Straight Education Network (GLSEN): www.glsen.org Human Rights Campaign (HRC): www.hrc.org It’s Pronounced Metrosexual: www.itspronouncedmetrosexual.com Lambda Legal: www.lambdalegal.org Parents, Families and Friends of Lesbians and Gays, Inc.: www.pflag.org

Cross-References ▶ Adult Sex Offenders Against Children: Etiology, Typologies, Investigation, Treatment, Monitoring, and Recidivism ▶ Bullying and Cyberbullying Throughout Adolescence ▶ Child Sexual Abuse Disclosure and Forensic Practice ▶ Forensic Interviewing ▶ Sexual Abuse of Children

Appendix A: Terminology (Austin and Craig 2015; GLAAD n.d.; Human Rights Campaign n.d.-c; Human Rights Watch 2016; Killermann 2017b; Killermann 2019; MAP 2012; Reisner et al. 2015) • Ally: A person who is not LGBTQ+ but shows support for LGBTQ+ people and promotes equality in a variety of ways. • Agender: A person who does not identify with any gender. • Androgynous: A term used to describe someone who identifies and/or presents as neither distinguishably masculine nor feminine. • Asexual: A person who experiences little or no sexual attraction to others and/or a lack of interest in sexual relationships/behavior. Asexuality exists on a continuum, and those on the continuum may have their own identity labels. • Bigender: A person who fluctuates between traditionally “woman” and “man” gender-based behavior and identities, identifying with two genders, or possibly a third, different gender. • Binary gender: Gender identity as either male or female.

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• Biological sex: a medical term used to refer to the chromosomal, hormonal and anatomical characteristics that are used to classify an individual as female or male or intersex. Also referred to as “sex assigned at birth.” • Biphobia: Prejudice, fear or hatred directed toward bisexual people. • Bisexual: A person who is emotionally, romantically, and physically/sexually attracted to both men and women. A bisexual person may not be equally attracted to both sexes, and bisexual people need not have had specific sexual experiences to be bisexual. May also use “pansexual.” • Cisgender: A gender description for someone whose sex assigned to them at birth and their gender identity correspond in the expected way. • Closeted: An LGBTQ+ individual who is not open to themselves or others about their sexual orientation or gender identity. Preferred term is “not out.” • Coming out: The process by which one acknowledges, accepts and appreciates one’s own sexual orientation or gender identity or the process by which one shares one’s sexual orientation or gender identity with others. A lifelong process of self-acceptance. • Deadnaming: Calling someone by their birth name after they have changed their name. This term is often associated with transgender people who have changed their name as part of their transition. • Gay: Typically used to describe a man who is primarily attracted emotionally, romantically, and physically/sexually to other men. Some women prefer to use this term to describe themselves, and the term may sometimes be used as an umbrella term for the LGBTQ+ community as a whole. • Gender dysphoria: Describes the distress a person may experience when perceived as a gender that does not match their gender identity, or from physical characteristics that do not match their gender identity. Many transgender people experience gender dysphoria at some point in their lives. In the most recent version of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), Gender Dysphoria is also the formal diagnosis applied to transgender people seeking mental health support for their transition. • Gender expression: Refers to external characteristics and behaviors such as clothing, hair style, mannerisms, speech patterns, social interactions, and so forth, which may or may not conform to socially defined behaviors and characteristics typically associated with being either masculine or feminine. • Gender-fluid: A gender identity best described as a dynamic mix of male/female and masculine/feminine. A person who is gender-fluid may always feel like a mix of the two traditional genders, but may feel more male some days, and more female other days. • Gender identity: One’s innermost (psychological) sense of being male, female or androgynous, a sense of being a blend of both or neither. One’s gender identity can be the same or different from their sex assigned at birth. • Gender minority: Describes a person whose gender identity or expression differs from societal and/or cultural norms associated with the gender binary (e.g., agender, bigender, gender nonconforming, genderqueer, transgender, two-spirited).

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• Gender nonconforming: A gender expression that is nontraditional (e.g., masculine woman or feminine man), or whose gender expression does not fit neatly into binary gender categories. • Gender normative: A person whose gender presentation aligns with society’s gender-based expectations. • Genderqueer: A gender identity label often used by people who do not identify with the binary of man/woman, or an umbrella term for many gender nonconforming or nonbinary identities. • Gender role: The set of expectations and behaviors assigned to females and males by society. Every culture and community has its own expectations about how men/boys and women/girls should behave, and these expectations often shift over time. • Heteronormativity: The societal or institutional assumption that heterosexuality is the only valid sexual orientation and is superior or preferable to being lesbian, gay, or bisexual, resulting in invisibility and stigmatizing of other sexualities. Heteronormativity also leads people to assume that only masculine men and feminine women are straight. • Heterosexism: Attitude and behavior affording preferential treatment to heterosexual people, providing reinforcement to the idea that heterosexuality is better than queerness, and/or makes other sexualities invisible. • Heterosexual/straight: Experience of emotional, romantic, or physical/sexual attraction to some members of a different gender. • Homophobia: The fear and hatred of, or discomfort with, people who are attracted to people of the same gender. • Homosexual: A term used to describe people who are attracted to members of the same sex/gender. Most people prefer the terms lesbian or gay, as the term homosexual is an outdated medical term and is often perceived as derogatory, offensive, or stigmatizing. • Intersex: An umbrella term used to describe a wide range of natural bodily variations. A variation in sex characteristics including chromosomes, gonads, or genitals that do not allow an individual to be distinctly identified as male or female. While some people can have an intersex condition and also identify as transgender, the two are separate and should not be conflated. • Lesbian: A woman who is primarily attracted emotionally, romantically, or physically/sexually to other women. Some lesbians may prefer to identify as gay or as gay women. • LGBTQ: One of several shorthand or umbrella terms for all individuals who have a nonnormative gender or sexuality: Lesbian Gay Bisexual Transgender and Queer and/or Questioning (+ is sometimes added in an effort to be more inclusive). Another acronym used is QUILTBAG for Queer/Questioning Undecided Intersex Lesbian Trans* Bisexual Asexual/Allied and Gay/ Genderqueer. • Lifestyle: Inaccurate term that many LGBTQ people find offensive. Avoid using this term; just as there is no one “straight” or “non-LGBTQ” lifestyle, there is no one LGBTQ lifestyle.

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• Mx: A title or honorific (e.g., Mr., Ms.) that is gender neutral. It is often the option of choice for individuals who do not identify within the gender binary. • Nonbinary: Any person whose gender identity is neither male nor female. • Out: A person who self-identifies as LGBTQ+ in their personal, public, and/or professional lives. Preferred term over “openly gay.” • Outing: Exposing someone’s LGBTQ+ identity to others without their permission. Outing someone can have serious repercussions on family relationships, personal safety, religious community, employment, and economic stability. • Pansexual/Pan: A person who experiences emotional, romantic, physical/ sexual, and/or spiritual attraction for members of all gender identities/ expressions. • Queer: Umbrella term that may be used to describe all people who are not heterosexual or gender conforming. For some LGBT people, this word has a negative connotation due to its historical use as a pejorative; however, many have embraced this term in place of LGBT. When Q is seen at the end of LGBT, it typically means queer and/or questioning. • Questioning: A person, often an adolescent, who is exploring or has questions about their sexual orientation, gender identity, or expression. • Sex: A category, usually either male or female, assigned based on physiological characteristics including chromosomes, sex hormone levels, and genitalia. • Sexual identity: This is how we perceive and what we call ourselves. Such labels include “lesbian,” “gay,” “bisexual,” “bi,” “queer,” “questioning,” “heterosexual,” “straight,” and others. Sexual identity (how we define ourselves) and sexual behavior can be chosen, unlike sexual orientation which cannot. • Sexual minority: Describes a person whose sexual or romantic attractions are not exclusively heterosexual (e.g., lesbian, gay, bisexual, mostly heterosexual or queer), or who experience same-gender attraction or engage in same-sex behavior, regardless of their gender identity. • Sexual orientation: Defines who a person is attracted to emotionally, romantically, and physically/sexually. Categories of sexual orientation include heterosexual, gay/lesbian, and bisexual and can be fluid over time. • Sexual preference: A term sometimes used incorrectly to mean the same thing as “sexual orientation.” Many LGBQ people find this term to be offensive because it implies that their sexual orientation is a choice. • Sexuality: How one experiences and expresses one’s self as a sexual being. • SOGIE: Acronym for Sexual Orientation, Gender Identity and Expression. • Straight: A person primarily emotionally, romantically, and physically/sexually attracted to some people who are not their same sex/gender. A colloquial term for the word heterosexual. • Third gender: Used for a person who does not identify with either male or female, but identifies with another gender. This gender category is used by societies that recognize three or more genders, both contemporary and historic, as a way to move beyond the gender binary. • Trans*: An umbrella term for a range of identities that cross socially defined gender norms.

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• Transgender: A broad term used to describe individuals who experience or express their gender in ways that do not correspond with social or cultural norms or expectations of the sex assigned to them at birth (natal sex). A transgender experience does not imply any specific sexual orientation. Therefore, trans people may be straight, gay, lesbian, bisexual, queer, etc. • Transition/transitioning: Refers to the process of a transgender person changing aspects of themself (e.g., their appearance, name, pronouns or making physical changes to their body) to be more congruent with the gender they know themself to be (as opposed to the gender they lived as pretransitioning). Transitioning may include social transitions, which may include being socially recognized as another gender; medical transitions, a method of modifying their body; and/or legal transitions, or changing names or gender markers on legal documents. • Transphobia: The fear and hatred of, or discomfort with, transgender people. • Transsexual: A dated term used to describe people whose gender identity does not conform to their sex assigned at birth and who often seek medical treatment to bring their body and gender identity into alignment. The term transgender is generally considered to be more appropriate. • Two-Spirited: A term for both same-gender and transgender people that emerged from various Native American/First Nations traditions to recognize individuals who possess qualities or fulfill roles of both feminine and masculine genders. • Ze/zir: Alternate pronouns that are gender neutral and preferred by some trans* people or those who do not use he/she or him/her.

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Adult Sex Offenders Against Children: Etiology, Typologies, Investigation, Treatment, Monitoring, and Recidivism

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Theodore P. Cross, Victor I. Vieth, Amy Russell, and Cory Jewell Jensen

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Etiology of Child Sexual Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Typologies of Adult Male Child Sexual Abuse Offender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Female Offenders of Child Sexual Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevalence of Female Offenders and Dynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Typologies of Women Who Sexually Offend . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “Grooming” Behavior: How Offenders Manipulate Victims and Institutions . . . . . . . . . . . . . . . . . Investigating Sex Offenders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Ms. Jensen’s contribution to this chapter is adapted from her article “Understanding and Working with Adult Sex Offenders in the Church,” published in volume 45(3) of Currents in Mission and Theology (2018). The journal Currents in Mission and Theology has granted the author permission to reproduce portions of that article in this chapter. This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. T. P. Cross University of Illinois at Urbana-Champaign, Champaign, IL, USA e-mail: [email protected] V. I. Vieth (*) Education and Research, Zero Abuse Project, St. Paul, MN, USA e-mail: [email protected] A. Russell Russell Consulting Specialists, LLC, Vancouver, WA, USA e-mail: [email protected]; [email protected]; [email protected] C. J. Jensen CBI Consulting, Inc., Portland, OR, USA © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_321

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Motive Evidence Involving the Offender or Victim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sexual Oddities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Photographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Victims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Incriminating Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Overview of Adult Sex Offender Management and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sex Offender Evaluations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sex Offender Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Management of Sexual Offenders in the Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Managing Sex Offenders in a Religious Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sex Offender Registration and Notification (SORN) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Residence Restrictions and GPS Tracking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Civil Commitment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recidivism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recidivism Rates Are Likely to Underestimate Re-offenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methodological Factors Affecting Recidivism Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Development of Sex Offender Policy in the United Sates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Sexual abuse of children is disturbingly frequent, making it critical to understand the behavior of sexual offenders against children. The etiology is not well understood, but likely involves biological, cognitive, and personality factors as well as offenders’ early life experiences. Offender typologies have been developed, although assessment often reveals a history of multiple types of offending. Female perpetrators account for a small percentage of sexual assaults against children and differ from male offenders in several ways. Offenders use methods of “grooming” children to be victims. Effective investigation methods require knowing characteristics of sexual offenders. Comprehensive evaluations include interviews, record review, standardized instruments, sexual arousal testing, and actuarial risk assessment. Treatment methods include challenging and replacing faulty cognitions and unhealthy sexual behavior, aversive conditioning, and risk management. Research has not yet provided convincing evidence for treatment effectiveness. Some evidence supports a containment approach to managing sexual offenders in the community that utilizes multidisciplinary teams, polygraph testing, and other control mechanisms. Special attention is needed to the risk and consequences of sexual offending within faith communities. Other management methods are also used, including sex offender registration and notification, residence restrictions, GPS tracking, and civil commitment, but research evidence is often lacking and some methods can have unintended negative consequences. Recidivism rates depend on multiple factors and are likely to be underestimated since many offenses are not detected. Increased knowledge supported by more research will grow our power to prevent child sexual and respond with excellence when it does occur.

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Keywords

Sex offender · Sexual offender · Grooming · Containment approach · Sex offender registration · SORN · Residence restrictions · Civil commitment · Recidivism

Introduction It is difficult to estimate the frequency of sexual offending against children because very few children (5–13%) disclose their sexual abuse (London et al. 2008). Therefore, rates from any official data on child sexual abuse are always underestimates. Nevertheless, the data that are available indicate that children and youth are at substantial risk. The most recent National Survey of Children’s Exposure to Violence (NatScev) in the United States, which interviewed youth and parents in a random sample of US households, found that 8.4% of youth aged 0–17 years old in the United States had experienced a sexual offense in their lifetime (Finkelhor et al. 2015). Adolescent girls are at much higher risk: other data from the NatScev shows that the lifetime prevalence of sexual abuse and assault among 17-year-olds is 26.6% (Finkelhor et al. 2014). Past surveys of adults indicate even higher rates. For example, the Adverse Childhood Experience study found that one out of four women and approximately one out of six men reported being sexually abused as children (Felitti and Anda 2010). Even though they underestimate the frequency of child sexual abuse, official data suggest the magnitude of the problem too. In 2018, the most recent year for which data are available, 63,000 children were involved in investigations of child sexual abuse by child welfare services (Finkelhor et al. 2020), which does not include many cases in which child welfare services was not involved because the perpetrator was not a relative or caregiver. Uniform Crime Report (UCR) data compiled by the federal Bureau of Justice Statistics based on reports to police indicate a recent increase in the risk of rape and sexual assault across age groups, from 1.1 per 1000 persons in 2014 to 2.7 per 1000 in 2018 (Morgan and Oudekerk 2019). However, UCR data combine child, youth, and adult cases, and we lack recent data on police reports for young victims. Understanding the complexities involved in child sexual abuse and sex offender behavior can contribute to helping law enforcement officers, child welfare workers, prosecutors, judges, and youth-serving organizations in protecting children, holding offenders accountable, and providing evidence-based treatment. Although this chapter cannot address all of the complexities involved, it can serve as an introduction and a guide for obtaining additional information.

The Etiology of Child Sexual Abuse Sex offenders can be any gender, race, ethnicity, or religion. They can have any occupation. The etiology is not well understood – “there is no simple answer as to why people engage in this behavior” (Faupel and Przybylski 2018). There is a dearth

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of rigorous research examining the causes of sexual offending against children (Stinson and Becker 2016). The research that has been done suggests that biological, cognitive, and personality factors may contribute to the development of sexual offending against children (Stinson and Becker 2016). Some studies have found differences in brain structure and function between child sexual offenders and other sexual offenders and non-offender comparisons, but not all child sexual offenders had these biological findings, nor do these findings help illuminate how sexual offending against children develops. Possible cognitive factors include distorted sexual beliefs about children (e.g., that adult sexual acts with children are not harmful) and sexualized perceptions of interpersonal behavior (e.g., perceiving that physically affectionate children have sexual interests). Possible personality factors include deficits in the ability to establish intimacy, empathy deficits, and limited social skills. Once an offender begins to sexually abuse children, the pleasure they gain may reinforce continued offending. Offenders’ childhood experiences play a role. Early exposure to aggressive pornographic material may be a factor (Marshall 1988). Many offenders report having endured various forms of child abuse and neglect themselves (Levenson et al. 2014). Contrary to previous beliefs, some experts report that child physical abuse and neglect may play a greater role than child sexual abuse in contributing to sexual offenses (Widom and Massey 2015). One of the challenges in assessing etiology is that sex offenders are manipulative and often lie about their histories. One study indicated that half of the offenders who initially told people that they had been sexually abused as children later acknowledged they had lied in order to appear less culpable for their crimes. In the end, only 30% maintained that they had been sexually abused, while nearly 70% reported that they started molesting children as a youth (Hindman and Peters 2001). While exposure to child abuse may be a risk factor, studies indicate that many sexual offenders against children do not have a personal history of abuse and neglect (Stinson and Becker 2016). Given the complexities of etiology, it is important that professionals do not overstep their bounds and assume they know the factors contributing to sexual abuse in a particular case. Instead, professionals should encourage or, if possible, require offenders to complete a comprehensive evaluation and risk assessment and should coordinate any ongoing work, such as a child welfare services case plan, with a qualified sex offender treatment provider.

Typologies of Adult Male Child Sexual Abuse Offender In recent decades, male sex offenders have been classified into two types, situational offenders and preferential offenders. Situational sex offenders typically prefer sex with other adults and do not have a sexual preference for children but may take advantage of children, particularly pubescent teenagers that they have access to (Lanning 2005). Criminal investigators have found these offenders to be less intelligent. They may have personality disorders (e.g., antisocial personality disorder, narcissistic personality disorder) and engage in a variety of criminal behavior

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(Lanning 2005). Researchers estimate that 50–60% of sexual offenders against young children fall in this category (Stephens and Seto 2016). Preferential sex offenders often have persistent sexual interest in juveniles, which leads them to prefer sexual activity with a child over sexual activity with an adult (Lanning 2005). Some individuals have pedophilia, which refers to a sexual interest in prepubescent children (Stinson and Becker 2016). Others have hebephilia, which refers to a sexual interest in youth in early stages of pubescence, usually between the ages of 11 and 14 years old (Stephens and Seto 2016). Criminal investigators have found that preferential offenders are often more intelligent and engage in focused criminal behavior that is often driven by fantasies (Lanning 2005). As a result, they have the potential to accumulate large numbers of victims (Lanning 2005). Professionals need to be aware, however, of the risk of underestimating sexual offending when categorizing sexual offenders by type. A number of studies have found that offenders who initially present with one type of sexual offending often, when carefully evaluated, reveal other types of sexual offending they have committed as well (Kleban et al. 2013; Office of Research and Statistics 2000). Polygraph examinations have been a tool to identify so-called crossover offending. Ultimately, professionals need to assess each offender’s history thoroughly and not rely on typologies for making decisions.

Female Offenders of Child Sexual Abuse Prevalence of Female Offenders and Dynamics Female offenders differ from male offenders not only in proposed typology and methodology of offending but also in how they are perceived by their victims and by society. As Levine wrote: Viewing females as perpetrators of sexual abuse challenges traditional cultural stereotypes. Females are thought of as mothers, nurturers, those who provide care for others; not as people who harm or abuse them. Since, historically, females have been viewed as noninitiators, limit-setters, and anatomically the receivers of sexuality, it is difficult for some to imagine a female sexually abusing others. (2006, p. 384)

Statistically, just over 3% of arrests for rape and less than 7% of other sex offense arrests (excluding forcible rape and prostitution) are attributable to women in the United States (U.S. Department of Justice 2018). However, these low arrest rates do not reflect the actual rates of sexual victimization of children and youth by females. This is a highly underreported crime, and the prevalence of female child sexual abuse offenders is estimated to be much higher than arrest rates indicate (Salter 2003; Tsopelas et al. 2011, 2012). Some research suggests that as many as 60% of male victims are sexually assaulted by females (Johnson and Shrier 1987), while others estimate the number to be closer to 20% (Salter 2003; Tsopelas et al. 2011, 2012). When sexually abused by a female, victims appear to have more intense concerns

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that they will not be believed if they report their abuse (Denov 2003). Male adolescent victims have reported being too ashamed to disclose victimization by a woman (Denov 2003). Landor and Eisenchlas (2012) point to the media as another source of social perceptions and bias about female offenders. The media often fail to report how victims of child sexual abuse are impacted by these offenses, particularly young male victims of adult female victims. These victims frequently are described as agents of seduction (Landor and Eisenchlas 2012). A dated but highly publicized example is the case of former Tacoma, Washington, elementary teacher Mary Kay Letourneau, whose adolescent victim was described in newspaper headlines as “Boy in Affair With Teacher” (Reuters, April 15, 2000) and “Jailed Teacher’s Teen Lover” (Los Angeles Times, October 19, 1998). Gender bias influences reactions to victimization of students by their teachers. Abuse of male students by adult female teachers is often perceived of as more acceptable than abuse of female students by male teachers (Dollar et al. 2004; Levine 2006; Tsopelas et al. 2011, 2012). When adult female teachers abuse adolescent male victims, it is often classified as sexual experimentation, and the juvenile victim is often adulated or deemed to be “lucky” to be guided into manhood. Media portrayal of male adolescent victims of abuse seems to indicate that it should be an enjoyable experience for the youth, a “learning experience” to be prized. Consequently, when a young male victim does not perceive his victimization as a positive experience, it may be highly confusing, and he may question his sexual identity during a critical time of sexual development (Dollar et al. 2004). Similarly, female adolescent victims of female sexual offenders may experience confusion and gender dysphoria. Female youth who sexually identify as lesbian or bi- or pansexual and are sexually victimized by a woman may wonder why they did not “enjoy the experience” and may question their sexual identity. Female youth who identify as straight may question their gender identity and wonder why they were targeted by a female offender. Some child sexual victimization by women may not be reported because of children’s developmental limitations or their lack of awareness of victimization. When abuse mimics child care activities or is associated with them, such as bathing or cuddling, a child may not know the actions are in fact illegal. Victims who do not recognize their experiences as abusive will not report the behaviors. Children may also be reluctant to report a primary caregiver as an abuser, as she is a source of safety as well as abuse.

Typologies of Women Who Sexually Offend Due to the dearth of research regarding women who sexually offend, identifying typologies for this population is challenging. Across studies, women who sexually offend are often under age 37 (Gannon et al. 2014; Tsopelas et al. 2011, 2012). Often they have their own history of victimization, they commonly experience mental health issues, and they are frequently dependent upon others. It is not uncommon for

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women who offend to be a friend or relative of the victim. Persuasion and psychological coercion appear to be more common means to control victims than aggression or violence, and child sexual abuse by women may result in more severe psychological consequences for their victims than sexual victimization of children by men (Tsopelas et al. 2012). Hines and Finkelhor (2007) proposed five types of females who sexually abuse adolescent males. The first is that of the “lover,” an older female who views the victimization as a sustainable relationship. The woman claims to be in love with the youth. The second type is the “teacher,” or a woman who interacts sexually with a young male as sexual initiation or to provide him with an education regarding sexual acts. This type does not see this interaction as a romantic or sustainable relationship. The third type, labeled “convenience or unaware,” involves casual sexual contact between an adolescent male and a young adult woman. The age of neither the woman nor the youth is a consideration in this typology; the youth does not attempt to appear older for the woman. The fourth type refers to prostitution, with an adult female being paid for sexual activity with an adolescent male. Hines and Finkelhor’s final type is “exploitation,” wherein the older woman takes advantage of a confused or inexperienced youth for her own sexual pleasure. Salter (2003) identifies three types of female offenders. Type One female offenders primarily offend against their own children, who are often under the age of 6 years. These women are “fused” with their own children and frequently display sadistic tendencies. Type Two offenders include teachers and lovers. Victims of these offenders are primarily adolescents; the age gap between offender and victim averages 16 years. Like Hines and Finkelhor’s (2007) “lover” type, Salter’s (2003) Type Two offenders romanticize the abusive relationship with their victim and are generally not sadistic in their interactions with the victim. Salter (2003) describes the Type Three female offenders as initially coerced into sexually abusing a youth by an adult male partner. These offenders are frequently motivated initially to please their male partner or to avoid abandonment by him. They often move on to sexually offending youth on their own. Salter (2003) points out that these female offenders have no parallel type among adult males who sexually abuse children. Wijkman et al. (2010) identify four female offender subtypes. One type, rapists, is characterized by serious penetrative offending with nonfamilial adolescents. Young assaulters are characterized by physically forceful non-penetrative abuse with male family members. Psychologically disturbed co-offenders have mental health problems and offend in the presence of one or more co-perpetrators. They have no particular victim preference. Wijkman et al.’s (2010) final subtype is passive mothers, who are characterized by passive acceptance or facilitation of male abuse of their own children. Gannon et al. (2014) developed their Descriptive Model of Female Sexual Offending (DMFSO) not as a typology or classification of offenders, but as a means to describe the series of behavioral, cognitive, affective, and contextual factors that lead up to – and are associated with – female-perpetrated sexual abuse. Gannon et al.’s (2014) model focuses on the aspects of planning, affect, coercion, and self-regulation of the female offender. This model helps explain the time period

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before the sexual offense, the offense itself, and the experiences of the perpetrator immediately after the offense. Gannon et al. (2014) identify and describe three pathways to female-perpetrated sexual victimization of children. The first is the explicit-approach pathway. Here, the offender may have various motives for offending, such as sexual self-gratification, desire for intimacy, or revenge against a perceived wrongdoer. There is not a preferred victim age, and women on this described pathway require little or no coercion from someone else to offend. In this pathway, the offenders tend to have explicitly planned their offending, and they experience a great deal of emotional pleasure as a result of their offending. In the directed-avoidant pathway, the offender does not want to sexually offend against children, but does so under the direction of a coercive and often abusive male, who alone plans the offending (Gannon et al. 2014). In this pathway, women comply only after extreme or prolonged coercion, often out of fear of the male cooffender or to obtain or maintain intimacy with him. Following the offense, these women typically experience significant negative affect as a result of offending. The third pathway is labeled implicit-disorganized. In this pathway, there is no one goal common to perpetrators for their offenses, and they may offend against adults and children alike. They are characterized by self-regulation deficits, and their disorganized and impulsive offending behaviors demonstrate a lack of explicit planning for the offense. Female offenders on this pathway may experience either negative or positive emotions following the offense. Robertiello and Terry (2007) suggest that these different typologies are not mutually exclusive. Each model may assist in identifying women who may be at risk to sexually offend or to recidivate; however, the research upon which the typologies were developed is limited and frequently relies upon self-reporting by offenders. Consequently, typologies may overlap in some areas and demonstrate distinct differences in other areas (Robertiello and Terry 2007). Investigators and supervision and treatment providers are advised to familiarize themselves with the various typologies of women who sexually offend. In this way, information from various typologies may provide guidance in the development of treatment strategies and sentencing recommendations, as well as decision-making and case planning for protecting children. At the same time, there may be limitations in using typologies for women offenders as there are for using them with male offenders. Crossover studies have not focused on female offenders, but it is possible that female offenders who present with one type of offending may have offended in other ways in their past as well.

“Grooming” Behavior: How Offenders Manipulate Victims and Institutions Given the fact that most sex offenders start offending at a young age and typically engage in a sometimes lifelong and varied history of offending, one can appreciate the learning curve involved. The goal of the offender is to remain undetected in the community. Remaining undetected requires purposeful planning and manipulation

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of children, adults, and institutions (Salter 1997). Offenders describe a progressive pattern of selecting and targeting vulnerable children and families; presenting themselves as a safe and trustworthy coach, youth minister, teacher, or other youth-serving professional; and committing their crimes in private. Their behavior with children is aimed at instilling trust and loyalty. They can trick their victim into believing that he or she is mutually involved and benefitting from the affection and attention that goes along with the sex abuse. Children become fearful of what might happen if anyone finds out or fearful they will get the offender in trouble and lose a close friend or mentor. Some offenders have even bragged about how easy it is to fool those around them. Grooming of a child may involve giving extra attention, gifts, or privileges to the child. Offenders may touch a child in an “innocent” way to gauge a reaction and then move on to more invasive touches. They may also “groom” a child’s parent by displaying kindness and creating an aura of being an upstanding person. An offender may groom an institution by doing good deeds for people in need and making an extra effort to help members of the community (Berkovits 2017).

Investigating Sex Offenders When law enforcement officers or other child protection professionals investigate an allegation of child sexual abuse, they need to consider the characteristics of the offenders. Both evidence collection and interrogation will differ, for example, for situational and preferential offenders and for male and female perpetrators. In cases of child sexual abuse, corroborating evidence plays a crucial role in whether criminal charges are filed (Walsh et al. 2010). Accordingly, it is critical for the investigator to find evidence supporting a child’s statements. The investigator can often find clues to offender characteristics in the details provided by a child in a forensic interview. If, for example, the child describes gifts and a gradual increase in touches and sexual comments consistent with grooming, it is more likely the offender is preferential. If so, evidence may include the following.

Motive Evidence Involving the Offender or Victim An offender with a preferential sexual interest in children may have sexually exploitive images on his phone or computer. He may have made comments in the presence of others about a child’s development and may be involved in multiple youth activities even though he does not have children of his own or children in the particular age group he is working with. In part because of grooming, a child victim may have expressed affection for an offender in the form of letters, artwork, or gifts (Vieth 2014). This is particularly so if the offender is a father or someone else the child may love. Evidence of this type shows the victim has no motive to fabricate since she cares for the offender. It may also show evidence of grooming.

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Sexual Oddities If a child describes an unusual practice of an offender, it may be possible to corroborate this oddity with other victims or adult sexual partners. In one case, for example, a child said an offender made a “whinny” sound as he climaxed and investigators were able to find adult sexual partners who confirmed the offender made this unusual sound when having an orgasm.

Photographs Taking pictures of the location or locations where the child was sexually abused can help a child testify and may bring to life a particular act to the jury (Vieth 2014). If, for example, a child says she was sexually abused in the room with a “giant eagle” and the investigators find a room with an eagle imprinted into the bedspread, it enhances the credibility of the victim, and she can confirm for the jury that that is the room she was referencing in a forensic interview (Vieth 2014). If a teacher sexually abuses a child in the classroom, the investigator must not only photograph the room but also note the proximate location of the crime. If the investigator can document the crime took place in a particular corner not visible to those passing by, it can explain the absence of witnesses and the efforts of an offender to conceal the crime.

Other Victims If there are indicators the offender is a preferential offender, then there is a real possibility, perhaps likelihood, of additional victims. Accordingly, investigators should consider whom else the offender had access to and who may have been at risk. When executing a search warrant at an offender’s home, investigators should be alert to the possibility of finding clues of other victims. In one case, for instance, investigators were searching for letters a victim said he had given the offender and discovered over 100 photographs of naked children in the suspect’s bedroom (Vieth 2014).

Incriminating Statements All sex offenders engage in cognitive distortions to justify their crimes. They may contend the abuse was a “relationship” or that the victim made advances or enjoyed the abuse. An offender may blame his wife because she withheld herself sexually. An offender may blame his conduct on depression or alcohol or some other factor. Understanding and incorporating these “outs” into an interrogation can be helpful in obtaining incriminating statements (Vieth 2014).

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Overview of Adult Sex Offender Management and Treatment Although the specific methodologies used in sex offender treatment programs vary, the goals are simple: protect the community by reducing re-offense rates and assist sex offenders in developing a balanced and pro-social (productive and non-criminal) lifestyle. Selecting an appropriate treatment begins with an assessment.

Sex Offender Evaluations Most credible programs (and not all providers are credible) begin with a comprehensive evaluation of each client (see, e.g., Schlank et al. 2016). This includes a thorough review of all pertinent police reports/victim statements and criminal records and an extensive interview process to collect social, educational, employment/military, sexual, and criminal history. Offenders also complete a battery of tests to assess mental illness or personality disorders (such as antisocial personality disorder) and psychological problems (such as depression, anxiety, or PTSD). Offenders complete standardized instruments that evaluate the degree of prooffending attitudes. Although few would outwardly admit it, child molesters tend to have distorted attitudes about the appropriateness or impact of child sexual abuse. Common beliefs for child molesters include “some children enjoy sexual contact with adults” and “not all children are harmed by sexual contact with adults.” Clinicians also employ sex offender-specific tests that measure sexual deviancy and compulsivity, plus other types of paraphilic behavior (exhibitionism, voyeurism, fetishism, bondage/discipline, sexual sadism, masochism, bestiality, etc.). In addition, denial, culpability, accountability, substance abuse, and the presence of appropriate social support systems are assessed along with the offender’s motivation to cooperate and make progress in treatment. One of the more common aspects of sex offender evaluation and treatment involves sexual arousal testing and aversive conditioning. Comprehensive programs use sexual arousal testing (via the penile plethysmograph) to determine the degree of arousal in response to victims of all age groups, to victims of both genders, and to violent scenarios. This involves attaching a strain gauge to the penis and measuring erectile responses while the person is exposed to various visual and auditory stimuli. A different type of test involves having the offender participate in visual reaction time measures (which measure the amount of time subjects look at images of children vs. how long they look at images of adults). Most agencies also require that offenders complete a “full disclosure” sexual history polygraph examination in order to collect all of the relevant sexual history information (see below). Clinicians who require full disclosure from offenders see expecting less as akin to treating a dangerous medical disorder without running all of the proper tests or determining how far the disease has spread. The last method of assessment involves actuarial risk assessment, using algorithms similar in form to those used by insurance companies to determine insurance

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rates. Actuarial risk assessment can assist in producing a more accurate picture of an individual’s risk. Voluminous research has identified risk factors for sexual offending. Among the risk factors that have predicted reoffending are younger offender age, previous arrest history (both sexual and non-sexual), sexual deviance (measured both by self-report and penile plethysmographs), antisocial behavior, difficulties regulating mood and anger, lack of cooperation with supervision requirements, and dropping out of treatment (Arnold and Davis 2016; Stinson and Becker 2016). Stinson and Becker also cite risk factors that are more specific to sexual offenses against children, for example, sexual interest in children or youth, problems with sexual self-regulation, and attitudes and beliefs that are characteristic of sexual offending. Several standardized risk assessment measures are commonly used based on this research. The research suggests that several are moderately good predictors of reoffending (Arnold and Davis 2016). In some cases, risk assessment has limitations. For example, an offender can sexually abuse 100 children and still be labeled as a “low risk” to recidivate (get caught again in the future) simply because he or she has gotten away with offending so often that the likelihood of being caught again is low. For youth-serving organizations, the best stance is to assume that all sex offenders present a moderate or higher risk of reoffending because believing someone poses a low risk may inadvertently predispose the organization to gradually allow the person to engage in risky behavior, which, in turn, increases the possibility an offender will harm another child.

Sex Offender Treatment Many sex offenders receive treatment, often mandated as part of their sentence (Hoberman 2016). Treatment can take place in prison, inpatient hospitals, or outpatient facilities. Sex offender treatment differs in a crucial way from other mental health treatment: the community is the client as well as the offender, because the most important goal of treatment is to prevent reoffending (Hoberman 2016). An influential conceptual framework informing sex offender treatment is Andrews and Bonta’s risk/need/responsivity (RNR) model (Andrews and Bonta 2010; Yates 2016). Risk refers to matching the intensity of intervention with the degree of risk associated with the offender. High-risk offenders need very intensive interventions. For example, Yates (2016) estimates that they need a minimum of 300 hours of treatment. Need refers to focusing on the so-called criminogenic needs of offenders, that is, those factors that research has found are associated with reoffending, such as sexual deviance and antisocial lifestyle. Responsivity refers to the treatment being tailored to the characteristics of the individual offender, such as personality style, intelligence, and learning style. Responsivity can help offenders engage with and make use of the treatment. The RNR framework has been one method for judging the quality of sex offender treatment. Sex offender treatment has multiple components that are used in conjunction with management methods discussed elsewhere in this chapter (Yates 2016). Most

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offenders participate in a combination of individual, group, and family/support group therapy. One focus of treatment is on challenging and replacing both faulty cognitions related to sexual offending and unhealthy sexual behavior (risky sex, pornography, etc.). Some treatment programs use aversive conditioning, discussed above. In addition, treatment requires that offenders develop and implement a risk management plan or relapse prevention plan. In this way, treatment responds to the criminogenic needs highlighted in the RNR model. Recent developments in treatment programming try to add to and go beyond the RNR model (Yates 2016). The Self-Regulation Model (SRM) identifies the pathways of experiences and behaviors in sequence that lead to sexual offending and provides a tool to help offenders recognize the pathway at each step and divert themselves from following the pathway. The Good Lives Model of Sexual Offender Rehabilitation goes beyond RNR by helping offenders build positive lives as well as avoid reoffending (Yates 2016). Such models help offenders develop pro-social lifestyles and relationships (relating to employment, social/recreational pursuits, and healthy intimate relationships with appropriate partners). Hoberman (2016) conducted an exhaustive review of the literature on the effectiveness of sex offender treatment. Numerous treatment outcome studies have been conducted, and several researchers have conducted meta-analyses that statistically combined the results of all adequate studies they found. All reviewers have noted the poor quality of the studies available. The biggest problem is the paucity of adequate comparison and control groups. One cannot adequately assess the impact of sex offender treatment without having a comparable non-treatment group to assess what change happens without treatment. The comparison groups that have been used are often not comparable. Using a comparison group of offenders who declined treatment is not adequate, for example, because offenders who declined treatment may inherently be more likely to reoffend – using such a comparison group could falsely produce a positive result. The limitations in study quality have led every reviewer of the research to draw only tentative conclusions. Hoberman (2016) concurs with several reviewers and finds no convincing evidence of a positive effect of treatment of sexual offenders for reducing reoffending. There is some evidence in lower-quality studies for a positive effect, but only for lower-risk offenders. When the review is limited to high-quality studies, there is no effect of treatment at all. One implication, according to Hoberman, is the need to rely on other management methods such as the containment approach (described below) in lieu of evidence that treatment impacts reoffending. Another conclusion he draws is that the treatment field must redouble its efforts to conduct high-quality treatment outcome studies, particularly since new treatment models such as SRM and Good Lives are promising, but have not been fully empirically tested. Hoberman (2016) and other reviewers concur with the Association for the Treatment of Sexual Abusers (ATSA) in calling for randomized clinical trials (RCTs) on sexual offender treatment. Considered the “gold standard” for evaluating interventions, RCTs randomly assign study participants to either a treatment group or a no-treatment control group. With a large enough sample, random assignment leads to groups that are comparable, because differences between individuals are randomly sorted into the two groups

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and any overall differences between the groups are simply the result of chance. Hoberman and many others maintain that only with RCTs can we learn whether treatment models using RNR, SRM, and/or Good Lives approaches truly have an impact on reducing the risk of sexual reoffending and improving offenders’ lives. Medication is an adjunct treatment for some sexual offenders (Nair 2016). Some offenders receive androgen-lowering medications that create hormonal changes to help reduce intense sexual thoughts and fantasies or violent urges. One term used for some forms of this treatment is “chemical castration,” which is reversible, unlike surgical castration. Selective serotonin reuptake inhibitors (SSRIs) are also used, and both types of medication have shown some success in reducing deviant sexuality. However, medications have only been effective with those whose sex drive plays a major role in their offending; they are not effective when offending is driven mainly by anger, hostility, or other emotional reasons. A very small number of sex offenders opt for surgical castration in which the testicles are removed (Sreenivasan and Weinberger 2016). The research indicates that the risk of reoffending following surgical castration is less than 10%. Ethical concerns have been raised about surgical castration. Surgical castration should only be done with the offenders’ informed consent, but critics have raised the concern that offenders are in effect coerced into surgical castration by the potential release from being committed to an institution (see discussion of “Civil Commitment”).

Management of Sexual Offenders in the Community It is critical that steps are taken to prevent sexual offenders from offending again once they return to the community on parole or probation. English, Heil, and Veeder (2016) describe a containment approach that many jurisdictions use to manage sex offenders in the community. English et al. (2016) cite several program evaluations that produced positive results for containment relative to comparison groups or to comparable recidivism statistics, such as those discussed below. One component of the containment approach is the use of multidisciplinary teams within and across agencies. Representation on these teams includes professionals from sex offender treatment programs, law enforcement, probation, parole, schools, social services, rape crisis centers, hospitals, prisons, and victim advocate organizations, as well as polygraph examiners and researchers. Teams share information and expertise that supports effective practice in general and also informs the management of specific offenders. An important goal is to develop a profile of information for each offender that is used to help prevent future offending. This includes information about offenders’ preferred victim types, sexual assault history, deviant sexual arousal and behaviors, and emotions, behaviors, and events that could increase the likelihood of a re-offense. In English’s model, risk management of offenders depends on three sources of monitoring: (a) supervision, (b) therapy, and (c) polygraph testing. Supervision is inherent to offenders being on parole or probation, with the criminal justice

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system empowered to use measures such as increased surveillance, enhanced treatment, and even imprisonment in response to parole violations. In a containment model, parole officers work closely with a multidisciplinary team that assists them with information gathering and decision-making. English argues that communities need to have sufficient resources to make supervision effective, such as limited caseloads for probation and parole officers and the establishment of halfway houses with 24-hour monitoring for selected offenders. She mentions a number of tools the criminal justice system has to enhance supervision, including lengthy probation and parole sentences, restrictions on high-risk behaviors, restrictions on contact with children, random home visits, urinalysis testing, and electronic monitoring. Sex offense-specific treatment (discussed above) is also thought to be necessary for containment. A promising adjunct intervention is Circles of Support and Accountability, in which community volunteers provide social support to sexual offenders released to the community without community supervision (Wilson et al. 2009). In English’s containment model, sexual offenders on parole or probation are also monitored regularly through polygraph testing. Post-conviction polygraph testing of sexual offenders does not focus primarily on detection of deception but instead on uncovering information that is useful for offender management (Grudin et al. 2019). Despite the claims of polygraph proponents (e.g., Grudin et al. 2019), who often selectively cite research reviews compiled by polygraph examiners with a vested interest in positive research findings, scientific evidence is lacking for the validity of polygraph testing for detecting deception (Iacono and Ben-Shakhar 2019). Moreover, there are special concerns with detecting deception of sexual offenders (Cross and Saxe 2001). Despite questions about the validity of the polygraph as a lie detector, ample evidence indicates that polygraph testing often leads sexual offenders to reveal undesirable information that can be useful to those managing them in the community (Cross and Saxe 2001; Grudin et al. 2019). For example, offenders may be more likely to disclose information about their history of offending and sexual preferences. The polygraph is also used to assess whether offenders are complying with the terms of their parole or probation. Regular polygraph testing while offenders are on probation also may act as a deterrent to reoffending (Grudin et al. 2019). A challenge with the use of the polygraph is whether its results on detecting deception should be used for decision-making regarding the offender, given concerns about its validity as a lie detector. Should, for example, passing a polygraph test about committing prohibited acts be made a condition for ending probation, if one cannot rely on polygraph results? Krapohl (2007) recommends a “successive hurdles” approach to polygraph testing, in which an initial positive result on deception is followed by repeated, more focused testing to try to confirm the initial positive finding and gather more information about it (see also English et al. 2016). However, this method has not been adequately evaluated, and it is not clear that this method would provide an improvement, given questions about the validity of the test as a whole and the possibility that examiner expectancy would influence the results (see Iacono and Ben-Shakhar 2019).

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Managing Sex Offenders in a Religious Community In a study of 3,952 male sex offenders, more than 93% of these offenders described themselves as “religious” or “very religious” (Abel and Harlow 2001). In a survey of 2,864 church leaders, 20% knew of at least one convicted sex offender who was attending services or was a member of their faith community (Liautaud 2010). Sex offenders who grew up in a religious community and stay within that faith tradition accumulate more victims and younger victims, and they get away with their offenses for longer periods than other offenders (Eshuys and Smallbone 2006). One reason for this is that faith communities typically have weak child protection policies and little training on child maltreatment, and offenders easily manipulate them (Vieth 2012). As one sex offender notes: I consider church people easy to fool. . .they have a trust that comes from being Christians. . .They tend to be better folks all around. And they seem to want to believe in the good that exists in all people. . .I think they want to believe in people. And because of that, you can easily convince [them], with or without convincing words. (Salter 1997, p. 29)

Tishelman and Fontes (2017) conducted a qualitative study in which they talked to 39 forensic interviewers who together had conducted over 42,000 child forensic interviews. The forensic interviewers reported that a large number of the children they had interviewed raised spiritual questions about abuse they suffered. The forensic interviewers also reported that faith communities would either help or hinder the response to the abuse (Tishelman and Fontes 2017). These and other studies suggest the value of multidisciplinary teams and children’s advocacy centers collaborating in developing and implementing child protection policies to protect children from abuse, manage sex offenders involved in a congregation, and address the spiritual needs of victims (Vieth and Singer 2019) and offenders (Vieth 2015).

Sex Offender Registration and Notification (SORN) In 1994, the United States Congress passed the Jacob Wetterling Act, which required all states to develop a registry to track sexual offenders in the community (LobanovRostovsky and Harris 2016). Originally, registries were designed solely as tools to be used by law enforcement, but Megan’s Law in 1996 amended the Wetterling Act to provide the public access to certain information about sex offenders. In 2006, Congress passed the Adam Walsh Act, which mandated further state sex offender registry requirements, specified a wider range of offenses that required registration, and established categories of sex offenders requiring different levels of supervision. All 50 of the United States and the District of Columbia maintain online registries of sex offenders that are accessible to the public and engage in notification. Both adults convicted of designated sex crimes and juveniles adjudicated as delinquent for designated sex crimes must register. The state notifies sex offenders of their responsibility to register and also notifies the offenders’ community of release from custody. The state

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also provides the public at large with information about sex offenders in the community (Bouffard and Askew 2019). Tier 3 offenders register for life, Tier 2 for 25 years, and Tier 1 for 15 years (Napier et al. 2018). Other countries such as the United Kingdom and Australia maintain sex offender registries as well, though they vary in whether the public has access to them (Napier et al. 2018). Sex offender registries are thought to help prevent reoffending in a number of ways (Pawson 2002). In theory, by providing a tool for law enforcement to monitor sex offenders, they increase the likelihood of arrest and thereby deter reoffending. They also provide community members with information to take precautions and monitor sex offenders more closely, both of which could decrease the likelihood of future sex offenses. For example, a faith community may learn a sex offender is attending religious services and may closely monitor him/her and prohibit him or her from any activities with the congregation youth (Tchividjian and Berkovits 2017). Registries add public exposure to the consequences of sexual offending, which is intended to have a deterrent effect against first-time offending (Pawson 2002). A number of studies have examined the impact of SORN legislation on sexual offending in the community, and most have found no effect (Bouffard and Askew 2019), particularly on reoffending. Exceptions are Letourneau and colleagues (2010), who found an 11% decrease in first-time sexual offenses over a 10-year period from the passage of South Carolina’s sex offender registration legislation in 1995, and Prescott and Rockoff (2011), who found that community notification regarding sex offenders was related to a reduction in the frequency of sexual offenses. However, Prescott and Rockoff (2011) also found a possible increased risk of reoffending among offenders who have their information communicated to the public and speculated that this could be due to the social and financial costs of community notification on offenders. Several publications have questioned whether the benefits of SORN legislation outweigh the costs (Prescott and Rockoff 2011), especially given the paucity of evidence for its effectiveness. SORN laws hurt sex offenders and their families financially and psychologically. Law enforcement agencies must devote time and money to implement registration and notification policies. Neighbors of sex offenders have seen decreases in property values following notification and do not necessarily feel a greater sense of security from having been notified. Prentky (1996) further suggests that SORN laws can induce a false sense of security in the public. Sandler and colleagues (2008) point out that SORN laws aim to prevent offenses by strangers, but the vast majority of sexual offenses are committed by persons known to the victim. They recommend community education to provide the public with accurate information about sexual offending.

Residence Restrictions and GPS Tracking The majority of US states have laws that prevent sex offenders from living near places frequented by children, including schools, daycare centers, parks, and bus stops (Lobanov-Rostovsky and Harris 2016). These laws affect where offenders

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sleep at night of course, but not where they can go during the day. Studies have failed to find that residence restrictions reduce the risk of reoffending (Lobanov-Rostovsky and Harris 2016). Duwe and colleagues (2008) found that the vast majority of child sexual abuse reoffenders made contact with a child through an adult (e.g., a parent) and knew the child before the assault, and none of the reoffenders made contact with the child in a place children congregate such as a school or park. Residence restrictions may have unintended consequences, because they are sometimes so restrictive that they contribute to offender homelessness, which can drive offenders to disconnect from authorities and fail to register. The negative effect of residence restrictions on offenders’ lives may create stress that increases the risk of reoffending (Lobanov-Rostovsky and Harris 2016). “Loitering zones” are an alternative to residency restrictions (Levenson 2016). These are places that children tend to congregate that sex offenders are forbidden to enter. Electronic monitoring using wireless anklet Global Positioning System (GPS) devices is another method used to deter and detect reoffending, and some states have passed mandatory lifetime GPS laws (Lobanov-Rostovsky and Harris 2016; Nieto and Jung 2006). Research on GPS with sex offenders is limited and has produced mixed results – one of the problems with the research is developing a comparable comparison group, since GPS is used with more serious offenders. Studies with comparison groups have found no effect of GPS on reoffending and have noted challenges such as insufficient staffing resources, signal problems, and equipment malfunction (Lobanov-Rostovsky and Harris 2016).

Civil Commitment Forty percent of the US states have laws allowing for civil commitment of high-risk sexual offenders (Hoberman and Jackson 2016). Other countries such as Canada, the United Kingdom, and the Netherlands also have civil commitment laws. Civil commitment involves the court ordering a high-risk sexual offender who has completed incarceration to remain engaged in treatment programs, mostly inpatient. The US Supreme Court has upheld the constitutionality of civil commitment laws. Ironically, the Court’s reasoning is based on the idea that civil commitment will lead to needed treatment, but those offenders likely to be civilly committed are the ones most resistant to treatment (Lobanov-Rostovsky and Harris 2016). A determination of civil commitment is based both the offender’s history of offending and a current evaluation of their risk. The evaluation considers whether offenders have a serious mental abnormality or personality disorder and assesses the offender’s capacity to control themselves. All civil commitment statutes allow for reversal of the commitment if offenders’ risk of reoffending lessens. Only 1–10% of incarcerated sexual offenders are civilly committed, which has resulted in over 4,000 offenders in the United States currently civilly committed or detained (Hoberman and Jackson 2016). It has been difficult to do research on civil commitment, so to date there are not empirical data supporting its use (Lobanov-Rostovsky and Harris 2016).

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Recidivism A major concern in dealing with sexual offenders is the risk that they will commit abuse again, known as recidivating (see, e.g., Kielsgard 2014; Patkin n.d.). Estimates of recidivism have influenced policy-making around sex offender registration and notification. Estimates of individual offenders’ risk of recidivism are also used in making sentencing and probation decisions in individual cases. Given its importance, it would obviously be valuable if exact estimates of the risk of recidivism could be determined for adult offenders of child sexual abuse and there was broad consensus about what the risks of reoffending are. However, results are quite variable across studies, for reasons we discuss below, and experts differ in their estimates of the true risk of perpetrators against children reoffending. Pryzbylski’s (2017) chapter for the Sexual Offender Management and Assessment Initiative of the federal Office for Justice Programs provides a balanced and useful overview that is a major source of the information in this section. One conclusion seems clear at the outset. The risk of recidivism is far below our worst fears and substantially less than the overwhelmingly large percentages that have sometimes been cited by legislators in advocating for legislation related to sexual offending. Patkin (n.d.) reports instances in which legislators have cited sex offender recidivism rates of 90% or greater. But reviews of research on recidivism of adult sexual offenders have found percentages that were much lower. Pryzbylski cited studies that found that 4.1 to 13% of child molesters released from prison were arrested, charged, or convicted (depending on the study) for a new sex crime within 3 years to 5 years after their release. Studies with longer follow-up periods have higher recidivism rates (Pryzbylski, 2017). Harris and Hanson (2004) found recidivism rates for 5-, 10-, and 15-year follow-up periods to be 13%, 18%, and 23%, respectively. Hanson, Scott, and Steffy (1995) found a 15- to 30-year sexual recidivism rate of 35%, and Prentky et al. (1997) found a 52% recidivism rate for a 25-year follow-up period. Pryzbylski notes, however, that methodological differences between studies could explain some of these differences in recidivism: the Prentky et al. (1997) followed incarcerated offenders only, while the Harris and Hanson (2004) study included offenders with less serious sentences serving a community sentence.

Recidivism Rates Are Likely to Underestimate Re-offenses Recidivism rates are likely to underestimate the actual risk of re-offense. Recidivism rates are calculated based on records of arrest, conviction, and incarceration, but research has shown that most sexual assault is not reported, and many cases reported to police do not result in arrest (Pryzbylski 2017). Pryzbylski further notes that under-reporting is especially great when there is a child victim who knows the perpetrator, which is true in the majority of child sexual abuse cases. There is substantial attrition at every step of the criminal justice process, so using conviction

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as a marker of recidivism leaves out all those cases in which the offender was not arrested, an arrest was made but criminal charges were not filed, cases were dismissed before reaching disposition, or perpetrators were acquitted at trial. Pryzbylski (2017) further points out that prosecuted cases tend to involve more violent offenses that are the most dissimilar from appropriate sex. More typical cases that do not involve violent offenses or involve somewhat less deviance are likely to be underrepresented in recidivism studies, but reoffending in these cases may be more common. Some types of offenses are especially difficult to prosecute, for example, sexual abuse against young children who are pre-verbal or against disabled victims who cannot testify. Children with these characteristics are at risk, but their cases are likely to be underrepresented in any recidivism study.

Methodological Factors Affecting Recidivism Rates A number of methodological factors affect recidivism rates across studies (Pryzbylski 2017). As our report of rates has already suggested, the duration of the follow-up period makes a major difference. The longer the follow-up period, the greater the amount of time is available during which an offender can recidivate. Even if the risk is constant at any given time point, recidivism must necessarily increase with a longer follow-up period. Another important factor in the variation in recidivism rates is what behaviors one includes as recidivism. The definition of recidivism varies from study to study, and several studies report several versions of the recidivism rate. Recidivism for sexual offenders can be defined in relation to committing sexual crimes or to committing any crime. Naturally, the broader the array of offenses specified for recidivism, the higher the recidivism rate. Recidivism rates also vary based on the specific offender population studied. Some studies are conducted with offenders released from prison, while other study samples consist of offenders discharged from probation. The former group includes more serious offenders and is likely to have a higher recidivism rate. Another methodological factor that decreases the recidivism rate in a study is counting as non-recidivating offenders whose circumstances rendered it unlikely to impossible for them to appear in criminal records measuring recidivism. Pryzbylski (2017) cites Heil and colleagues (2009), who found a higher recidivism rate than comparable studies simply by eliminating from their sample offenders who moved out of state or died or whose residence could not be verified (17% of their original sample). Soothill (2010) provides a detailed discussion about how sample selection biases can influence recidivism rates. Determining an exact recidivism rate is elusive, and the risk of recidivism for individual offenders will vary based on the time span examined, the type of offender, and the risk factors that are present. While the risk of recidivism is clearly less than it sometimes has been portrayed, it is large enough that it justifies investing in effective management and treatment methods and maintaining a healthy degree of vigilance.

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The Development of Sex Offender Policy in the United Sates Lobanov-Rostovsky and Harris (2016), citing the criminologist Sutherland, describe a revealing historical pattern for the development of sex offender policy in the United States. First, a high-profile sexual assault case hits the news. Often these sexual assaults are by strangers and involve kidnappings, murder, or other violence as well as sexual assault. The publicity leads to public clamor for action, and legislators react by passing legislation instituting a variety of social controls over sexual offenders. The focus is more on preventing recidivism than preventing first-time offending, and the measures have tended to be based primarily on violent stranger assaults, which are disproportionately represented in highprofile, high-publicity cases. These measures sometimes apply the same or similar intervention to a wide range of sexual offenders, despite the heterogeneity and substantial differences in risk across the population of all sexual offenders. These actions have led to SORN laws, residence restrictions, civil commitment laws, and longer terms of incarceration. They require substantial public investment of money and time, particularly law enforcement hours, and they can have serious “side effects” (e.g., residence restrictions increasing the likelihood of homelessness). Yet they are not particularly well suited to most child sexual abuse cases. Usually child sexual offenses are committed by adults or youths who are well known to the child and family, sometimes by offenders who are not likely to be candidates for the more severe interventions. These measures may have some deterrent effect on first-time offending, but otherwise they do not address prevention. No doubt, intensive control measures are necessary to counter serial offenders. But there is also an urgent need to improve management, treatment, and supportive interventions based on empirical findings and to continue developing new research findings to improve the response. Policy-making and public investment to combat sexual offending needs to be based on all data about sexual offending and not just high-profile cases.

Key Points • Children and youth are at substantial risk for sexual abuse, e.g., the lifetime prevalence of sexual abuse and assault among 17-year-olds is 26.6%. • Although rigorous research is lacking on the causes of sexual offending against children, biological, cognitive, and personality factors may contribute as well as specific experiences such as early exposure to aggressive pornography and offenders’ personal history of abuse and neglect. • Male sex offenders include both situational sex offenders who do not have a sexual preference for children, pedophilic offenders with a sexual preference for prepubescent children, and hebephilic offenders with a preference for youth in early pubescence.

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• Crossover studies demonstrate the limitations of sex offender typologies, because evaluations of offenders who present with one type of sexual offending often reveal a history of other types of offending as well. • Female perpetrators account for a small percentage of sexual assaults against children. • Female perpetrators differ from male offenders in typology and methodology of offending and in how they are perceived by their victims and by society. • Offenders “groom” children, targeting vulnerable children and families, presenting themselves as safe and trustworthy youth-serving adults, and committing the majority of their crimes in private. • Comprehensive evaluations are needed that include interviews, record review, standardized instruments, sexual arousal testing, and actuarial risk assessment. • Treatment methods include challenging and replacing faulty cognitions and unhealthy sexual behavior, aversive conditioning, and developing and implementing a risk management plan. • Research on the efficacy of sex offender treatment has a number of weaknesses and has not yet provided convincing evidence that treatment is effective in reducing recidivism. • Some evidence supports the effectiveness of a containment approach to managing sexual offenders in the community that utilizes multidisciplinary teams, polygraph testing, and other control mechanisms. • Many sex offenders are religious and offend within faith communities; this supports the need for collaborations between multidisciplinary teams and faith communities to prevent abuse, monitor sex offenders, and address the spiritual needs of victims and offenders. • Methods such as residence restrictions, GPS tracking, and civil commitment are used to manage sex offenders, but these methods do not have a solid research base, and some may have unintended consequences. • Multiple factors are involved in recidivism and no single recidivism rate can be determined, in part because recidivism rates do not include re-offenses that are not detected.

Summary and Conclusion Although it is challenging to determine the prevalence of child sexual abuse in the United States precisely, it is clear that the rate is high. In order to reduce child sexual abuse, all professionals who respond to these cases must be fluent in the current research and employ this research in prevention policies, in the investigation and prosecution of adult sex offenders, and in treatment selection. Different approaches will be needed depending on whether the offender is a male or female and on the offender’s history of offending. In going forward, all professionals will need a sense of humility. We do not yet have clear evidence that treatment is effective and thus more and better research is needed. Similarly, while there is some reason to believe containment may be

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effective, it also appears that not every intervention to manage sexual offending is effective. Again, an investment in more and better research is needed. As sex offender treatment provider Anna Salter has written, “Child abuse leaves a footprint on the heart” (Salter 2003). The sexual abuse of a child can result in a lifelong impairment of the victim’s physical and emotional health (Felitti and Anda 2010). As our awareness of these consequences expands, so must our knowledge of the men and women who violate children. Increased knowledge will also grow our power to prevent these crimes and, when they cannot be prevented, to respond with excellence.

Cross-References ▶ Sexual Abuse of Children ▶ State-of-the-Art Measures: Contemporary Views on Risk Assessment of Sexually Abusive Youth ▶ The Commercial Sexual Exploitation of Children ▶ The Criminal Justice Response to Child and Youth Victimization ▶ The People in Your Neighborhood: Working with Sexual and Gender Minority Youth as Victims of Sexual Violence

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Contents Risk Assessment Tools: Risk Prediction and Calibrated Risk Levels . . . . . . . . . . . . . . . . . . . . . . . . . Construction of Risk Assessment Tools for Sexually Abusive Youth (Adjudicated and Non-adjudicated) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Review of Risk Assessment Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Risk and Protective Factors: Assessing Different Types of Sexually Abusive Youth (Adjudicated and Non-adjudicated) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Children Ages 4 to 12 Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sexually Abusive Youth with Low Intellectual Functioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Transgender Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sexually Abusive Female Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sexually Abusive Youth Who Are Inconspicuous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

This discussion of risk assessment tools and sexually abusive youth brings forth the most current assessment tools and methods developing in the field of risk assessment. Presented is the twenty-first century New Paradigm of inclusive

This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. L. C. Miccio-Fonseca (*) Clinic for the Sexualities, San Diego, CA, USA e-mail: [email protected] L. A. L. Rasmussen San Diego State University, School of Social Work, San Diego, CA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_313

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ecologically based, developmentally and gender-sensitive assessment tools. These are anchored in scientific study for accuracy to assess risk and protective factors of sexually abusive youth. Risk assessment of sexually abusive youth is a specialty that ideally takes place within a broader clinical assessment (e.g., psychological evaluation) and utilizes validated measures with proven accuracy. This chapter discusses contemporary issues that must be considered when assessing risk of sexually abusive youth. Keywords

Adolescent sex offender · Sexually abusive youth · Female sex offenders · Transgender youth · Risk assessment tools · MEGA♪ · Sexually abusive youth with low intellectual functioning · Sexually violent and predatory youth Since our publication of “Scientific Evolution of Clinical and Risk Assessment of Sexually Abusive Youth: A Comprehensive Review of Empirical Tools,” in the special issue, entitled Risk Assessment of Sexually Abusive Youth, in the Journal of Child Sexual Abuse (Miccio-Fonseca and Rasmussen 2018), important benchmarks have taken place in the field of risk assessment tools. Further evolution of a paradigm change is evidenced by empirical findings disseminated from a variety of studies and a call by a well-known researcher in the field (Caldwell 2019, Summer) to cease the implementation of “juvenile sexual recidivism risk assessments” (Slide 45). Caldwell’s call marked a turning point, a move away from risk recidivism predictive tools for youth to using tools with calibrated risk levels (Caldwell 2016). As this chapter goes to print, the United States is approaching close to 200,000 deaths from the COVID-19 pandemic. The pandemic's impact means a reinvention in all fields, including the field of risk assessment. Every societal function has been impacted by the global pandemic (i.e., education at all levels [day care, preschool, elementary, junior high, high school, community colleges, universities], medicine, mental health systems, court systems, detention and correctional facilities, hospital systems, clinics, businesses [industrial, technical, domestic, and international], world trade, all financial systems [banking, real estate, foreclosures, commercial property, accounting systems, collections and payment systems). Equally impacted are cultural traditions, customs, and beliefs; all are recalibrated. Therefore, what is presented in this chapter are paradigms that are pre-COVID-19, some of which can be quite applicable and others not. Nevertheless, the chapter provides a baseline anchored of the most current scientific research on a difficult population to study. This chapter describes a New Paradigm (i.e., considering age and gender when assessing risk) occurring in the field of risk assessment for youth. Using tools that have risk levels calibrated according to age and gender potentially will align the field more closely to the gold standard, that is, to the guidelines of the American Psychological Association for creating psychometric tools (American Educational Research Association [AERA] et al. 2014). “Youth” references all young people (children, pre-adolescents, adolescents, up to the age of 19 years, 11 months, and 29 days), in essence, the developmental period from childhood to young adulthood.

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Risk Assessment Tools: Risk Prediction and Calibrated Risk Levels Risk assessment tools for sexually abusive youth basically fall into two categories, risk recidivism (predictive) and risk level (calibrated), which have evolved over a 20-year period from tools based on clinical judgment to tools that are scientifically constructed and tested (Miccio-Fonseca and Rasmussen 2018). The first tools were the Juvenile Sex Offender Assessment Protocol (J-SOAP/J-SOAP-II – Prentky et al. 2000; Prentky and Righthand 2003) and Estimate of Risk of Adolescent Sexual Offense Recidivism, Version 2.0 (ERASOR – Worling and Curwen 2001); both tools are structured professional judgment risk recidivism (predictive) tools providing an ostensibly more objective method (other than interviews) to assess a youth’s risk. Assessed risk levels were not exact, but an “educated guess” based on professional judgment. The twenty-first century brought the advent of scientifically constructed, statistically robust risk assessment tools tested on large representative samples. These contemporary tools are the Juvenile Sexual Offender Recidivism Risk Assessment Tool -II (Epperson et al. 2006; Epperson and Ralston 2015), a risk recidivism (predictive) tool, and MEGA♪ (Miccio-Fonseca 2009, 2010, 2013, 2018a, b, 2019), a tool with normative data ensuring confidence in the accuracy of the risk levels, a significant improvement over J-SOAP-II and ERASOR. Name of the tool is MEGA♪, as copyrighted and registered by the author, L.C. Miccio-Fonseca, Ph.D., which includes the musical note. California Coalition on Sexual Offending provided a $2000 research award, which was used for the final statistical analysis of the cross-validation study. L.C. Miccio-Fonseca, Ph.D., sole creator of the MEGA♪ Risk Assessment Tool, receives profit from product sales funding the ongoing multiple research projects. Sexual recidivism rates reported for sexually abusive adolescents are low, making it difficult to test predictive validity of a measure. In a meta-analysis of 106 studies (from 1938 to 2014), Caldwell (2016) compared recidivism of adjudicated juvenile sexual offenders (N ¼ 33,783) followed for a mean of 62.06 months (5 years, 1 month). Caldwell reported “. . .the most appropriate estimated base rate for sexual recidivism over full data set falls approximately between 3 and 10%, with a global average of approximately 5%” (p. 6). Calculating recidivism is never exact, given that sexual abuse is an underreported crime. National crime surveys show that 3 out of every 4 sexual assaults are not reported to police (Rape and Incest National Network [RAINN] n.d.). Recidivism studies are primarily comprised of adjudicated male adolescents. Sexual recidivism rates of non-adjudicated youth, females, children under age 12, and youth with low intellectual functioning are unknown. Risk recidivism (predictive) tools are validated through predictive validity studies, typically using receiver operating statistics (ROC) analysis and the (AUC) statistic, which represents the area under the ROC curve. Each tool has identified predictive variables specified by its author that are assessed for their utility for detecting a re-offense. Depending on the study, predictive variables may include arrest, charge, adjudication, sanctioning by an adult, report of new sexually abusive behavior, and self-report (e.g., see meta-analysis [N ¼ 6196, 33 studies] by Viljoen et al. 2012).

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Two decades ago (2000), the need for risk assessment tools was extremely high, resulting in quick adoption and implementation of J-SOAP-II and ERASOR, even though they had only been validated on very small samples (respectively: N ¼ 96 [Prentky et al. 2000] and 136 [Worling 2004]). The first independent studies of J-SOAP-II did not appear until 7 years after its construction (Martinez et al. 2007), while the first independent study of the ERASOR was a dissertation study published 4 years after the tool was introduced (Costin 2005). Subsequent independent studies brought disappointing news, evidenced in a meta-analysis (Viljoen et al. 2012) documenting only moderate predictive validity for both tools and a systematic review (Hempel et al. 2013) demonstrating that neither J-SOAP-II or ERASOR nor other risk recidivism (predictive) tools reviewed “showed unequivocal positive results in predicting future offending” (p. 208). In their review of nine studies utilizing the J-SOAP-II, Fanniff and Letourneau (2012) cautioned that until “more consistently supported by empirical evidence, evaluators should not base significant decisions” (p. 403) on J-SOAP-II results. Schwartz-Mette, Righthand, Hecker, Dore, and Huff. (2019) reported that J-SOAP-II had good predictive validity for adult recidivism on a small sample (N ¼ 166) in a longitudinal study. The number of cases with missing data in archival records was not reported for this small sample, which may have inadvertently impacted the findings, thus possibly affecting the predictive validity findings. Likewise, Worling, one of the authors of the ERASOR, affirmed he was discontinuing his use of the ERASOR, since “the average degree of accuracy is poor for making forensic decisions” (Worling 2017, June). Caldwell (2019, June) specifically named J-SOAP-II, ERASOR, and JSORRAT-II when he asserted professionals should “stop doing juvenile sexual recidivism risk assessments” (Slide 45). Declaring that these tools are not reliable and “do more harm than good” (Slide 47), Caldwell stated that they have risk factors that either were not validated with adolescents or were adopted from templates from adult risk assessment tools. Other researchers have asserted that applying empirical findings on adult convicted sex offenders to juveniles is inappropriate (Powers and Sawyer 2009). Validation research and independent studies on J-SOAP-II and other risk assessment tools are presented in detail in our comprehensive review, “Scientific Evolution of Clinical and Risk Assessment of Sexually Abusive Youth” (MiccioFonseca and Rasmussen 2018). JSORRAT-II (Epperson et al. 2006; Epperson and Ralston 2015), a risk recidivism predictive tool, and MEGA♪ (Miccio-Fonseca 2009, 2010, 2013), a risk level tool, are the only risk assessment tools for sexually abusive youth to be tested on samples totaling greater than 1,000 youth and have normative data (i.e., cut-off scores), considerably increasing the likelihood findings can be generalized to the overall population of sexually abusive youth. Normative data sets allow assessment of risk to be made based on sound empirical data, rather than guess estimates inherent when risk assessment tools (e.g., J-SOAP-II, ERASOR) rely on clinical judgment. JSORRAT-II, the only actuarial risk assessment tool for youth, was constructed and cross-validated on samples totaling 1,731 adjudicated youth (Epperson and

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Ralston 2015; Ralston et al. 2016). Normative data and cut-off scores make the JSORRAT-II superior to J-SOAP-II and ERASOR; however, it is nonetheless a risk recidivism (predictive) tool that has shown inconsistent predictive validity in validation studies (Epperson and Ralston 2015; Ralston et al. 2016) and moderate predictive validity in independent studies (Viljoen et al. 2012). Caldwell (2019, June) mentioned JSORRAT-II (along with J-SOAP-II and ERASOR) when he recommended professionals stop using juvenile sexual recidivism risk assessment tools. Risk level tools (e.g., MEGA♪) have calibrated risk levels grounded on given algorithms (i.e., cut-off scores according to age and gender), established by testing and retesting the tool on large representative samples (at least 300–500 subjects). Cut-off scores make a risk assessment tool more definitive, enhancing prognostic utility. Cut-off scores are discriminating, like a person’s shoe or clothing size. For example, an adult male going into a clothing store does not shop in the children’s section; the size range is different. Likewise, a parent who takes a 10-year-old girl shopping does not go to the section for infants and toddlers. The range of sizes thus differs according to the age and gender of the individual. So it is with cut-off scores for calibrated risk levels for sexually abusive youth. A calibrated risk level tool will have scoring ranges that differ according to the youth’s age group (e.g., ages 12–15 vs. 16–19) and gender. Thus, a 14-year-old boy would be scored differently than a 17-year-old girl. The MEGA♪, a risk level tool with four calibrated risk levels, according to age group and gender (i.e., low, moderate, high, very high), introduced a new paradigm of risk assessment measures that is ecologically based, empirically anchored on research on youth, and developmentally and gender sensitive. While prior risk assessment tools (e.g., J-SOAP-II, JSORRAT-II) were constructed for male adolescents, MEGA♪ is applicable to males and females, ages 4–19 (adjudicated and non-adjudicated), including youth with low intellectual functioning. MEGA♪ was validated and cross-validated on several large representative international samples (adjudicated and non-adjudicated youth in three age groups: 4–12, 13–15, 16–19) totaling 3,901 sexually abusive youth). A few independent studies have been completed on the JSORRAT-II (Rasmussen 2017; Viljoen et al. 2008) and on MEGA♪ (Fagundes 2013; Rasmussen 2017). In June 2019, concurrent with Caldwell’s call to “stop doing juvenile sexual recidivism assessments” (Slide 45), Kang, Prentky, Righthand, Worling, and coauthors introduced the Treatment Needs and Progress Scale (TNPS), a new protocol for assessing “juveniles with sex offenses” that appears loosely based on the RiskNeeds-Responsivity (RNR) model, a paradigm for adult sex offenders. Applying the RNR model to youth has limited research support. J-SOAP-II and ERASOR were among the tools selected to provide the item pool for the TNPS (see Kang et al., p. 159), even though they were created from templates of adult tools, with risk factors that were associated with convicted adult sex offenders (Caldwell 2019; Miccio-Fonseca and Rasmussen 2018). Some items in TNPS reflect J-SOAP-II’s Sexual Drive and Preoccupation scale. Fanniff and Letourneau (2012) reviewed nine studies utilizing J-SOAP-II, concluding that this scale “cannot be interpreted with

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confidence as indicating a youth’s propensity to commit future sexual offenses” (p. 386). As mentioned above, Worling, one of the senior authors of the TNPS protocol and tool, and a co-author of the ERASOR (Worling and Curwen 2001), discontinued his own use of the ERASOR, stating “A number of risk factors were included in the ERASOR back in 2000-2001, as they were judged to be promising at that time based on the available research and clinical expertise. This is no longer the case for several of the risk factors, however, based on more recent research. Of course, this significantly compromises the validity of the ERASOR” (2017, June). Citing Miner (2002), Powers-Sawyer and Miner (2009) cautioned against applying risk factors for adults to adolescents, stating “many adult risk factors were either unrelated to adolescent reoffending or behaved differently in adolescents than they did in adults”(p. 2). The TNPS repeats the cardinal mistake of the past (i.e., fashioning tools partially anchored in research on adult convicted sex offenders). Kang, Prentky, Righthand, Worling, and co-authors (2019) reported they are currently conducting a pilot study on the TNPS. However, Miccio-Fonseca’s (2020) critique found the study lacking in basic essential components typically reported in research proposals or briefs: (a) an operational definition of terms; (b) discussion of the applicability of the tool (i.e., what type of youth are to be assessed? [e.g., adjudicated and/or non-adjudicated, males and/or females, youth with low intellectual functioning]); (c) description of the validation sample (i.e., age, gender, adjudication status, and type of setting for research sites [e.g., outpatient vs. residential and/or correctional]; and (d) current literature review of samples studied. Nevertheless, Kang et al. (2019) followed to some degree the New Paradigm of risk assessment by incorporating in the TNPS many major aspects of the template of MEGA♪, including assessing protective factors and using age groups (in their case – 10–14, 15–17, 18–25 – see p. 159). Prentky et al. (2020) completed their pilot study, along with renaming of the tool without explanation to Youth Needs and Progress Scale [YNPS]), and neglect to address many of the multiple concerns raised in Miccio-Fonseca’s (2020) critique.

Construction of Risk Assessment Tools for Sexually Abusive Youth (Adjudicated and Non-adjudicated) Sophisticated tools constructed according to the scientific method engender confidence. Examples can be seen in the medical field. An echocardiogram can identify structural deficiencies in the heart that pose risk for cardiac problems. An MRI can differentiate subtle abnormalities in the brain and assist in accurately diagnosing a tumor. Blood tests can home in on markers of diabetes or other chronic health conditions. The same is true with scientifically constructed, validated risk assessment measures constructed by testing and retesting variables on large representative samples (e.g., JSORRAT-II and MEGA♪). They can identify critical areas of concern that pose risk for sexually abusive behavior, are more objective, and result in greater accuracy.

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There are very few professionals who are both researchers and have the expertise in psychometrics needed to construct risk assessment tools; this type of research takes considerable time and funding, often impeding independent studies. Standards of psychometric test development (i.e., the Gold Standard, articulated by the American Educational Research Association [AERA], American Psychological Association [APA], and National Council on Measurement in Education [NCME] 2014) should guide psychologists who construct risk assessment tools. Essential steps for developing a new measure include obtaining input from professionals and/or researchers, completing a comprehensive literature review, obtaining a sizable sample, completing pilot studies, and then validating and cross-validating the measure with different multiple samples, thus assuring predictive accuracy and generalizability. A tool not meeting these standards is deficient; therefore, the user cannot have confidence in the results (Glaser 2018). Obtaining large representative samples in risk assessment research is a formidable task. Not doing so, however, leaves a trail of likely inaccurate perceptions of risk level and recidivism rates that are based on questionable findings from non-representative samples. The twenty-first century New Paradigm for risk assessment measures for sexually abusive youth requires the construction of tools that use socially contextual, static, and dynamic risk and protective variables (MiccioFonseca 2018a) and are sensitive to differences related to developmental level and gender. Judicial systems turn to psychologists, experts in constructing psychometric measures, for authoritative methods on assessing risk level of sexually abusive youth. Risk assessment is a specialty completed by trained professionals working with youth with problematic sexual behaviors that may be sexually abusive. The risk assessment may accompany a comprehensive psychological evaluation, but is not equivalent to it. Risk assessments do not incorporate the array of factors that psychological assessments and/or psychological evaluation address. Psychological evaluations are completed by doctoral-level, clinically trained, licensed clinical psychologists using psychometric measures assessing multiple aspects of functioning (i.e., cognitive and neuropsychological processes, somatic symptoms, personality traits, psychopathological symptoms, behaviors, and interpersonal relationships [Karsten and Dempsey 2018]). A variety of professionals with different levels of educational backgrounds and work experience in different capacities can complete risk evaluations; an individual can be either a licensed (e.g., psychologist, clinical social worker) or non-licensed (e.g., probation officer, child welfare social worker) professional.

Review of Risk Assessment Tools We refer the reader to our article “Scientific Evolution of Clinical and Risk Assessment Tools” (Miccio-Fonseca and Rasmussen 2018) for comprehensive discussion of validation and cross-validation research and independent studies of the various risk assessment tools and their applicability to different populations (e.g., adjudicated vs. non-adjudicated youth, males and/or females, adolescents vs. children,

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youth with low intellectual functioning). Included in our review were the risk recidivism tools that have the most independent research, that is, J-SOAP-II and JSORRAT-II, with brief mention of ERASOR. We also reviewed risk assessment tools that (a) have only one validation study (e.g., New Jersey Juvenile Risk Assessment Scale (JRAS – Hiscox et al. 2007) and Assessment, Intervention, and Moving on Project 2 (AIM2; Griffin et al. 2008) and (b) unvalidated tools with no empirical research (Juvenile Risk Assessment Tool [J-RAT – Rich 2017]; Protective + Risk Observations for Eliminating Sexual Offense Recidivism [PROFESOR], Worling 2017, June). JRAS was intended to be a risk recidivism (predictive) tool, but predictive validity was only moderate in its single validation study on a small non-representative sample (N ¼ 231). AIM2 is a structured professional judgment tool in the United Kingdom that assesses “concerns and strengths.” It demonstrated excellent predictive validity in a single validation study of a very small sample (N ¼ 70), therefore “cannot be considered validated or fully reliable” (Griffin et al., p. 222). Our 2018 review also mentioned the Multidimensional Inventory of Development, Sex, and Aggression (MIDSA) created by Dr. Raymond Knight (Augur Enterprises, Inc. 2011), a comprehensive, robust risk management instrument. Two unvalidated tools discussed in our 2018 review, J-RAT and PROFESOR, have face validity only. Until empirically researched, it is not possible to determine what type of tools they are or their level of accuracy. No research has been reported on J-RAT, although it was created over a decade ago (Rich 2009). Worling (2017, June) neglected to follow the expected protocol for constructing psychometric tools (AERA et al. 2014) when he released the PROFESOR for use without providing (a) an instructional manual for users, (b) parameters regarding level of experience and training needed for administration, (c) instructions for scoring, and (d) a discussion of the tool’s limitations. An instructional manual has since been provided, and there are ongoing trainings. However, without published research, using the PROFESOR or J-RAT is questionable. We also touched briefly in our 2018 review on the practice of applying what we referred to as “utility tools” (i.e., polygraph, plethysmograph) to youth. These methods migrated from common use with adult sex offenders and surprisingly continue to be employed even though there are no standardized methods or evidence-based guidelines for administering them to youth. Polygraphers are not required to have any kind of specific training and education related to developmental issues, including needs of youth of different genders and/or age groups, with physical and/or learning disabilities, and/or with low intellectual functioning. Chaffin (2011) pointed out that using the polygraph with youth may result in potential harm if used “to coerce incriminating confessions from a juvenile, intending that this will result in the juvenile’s prosecution or sanctioning” (p. 321). He warned professionals against embracing “unusual, coercive, and intrusive practices with minors without simultaneously undertaking the rigorous testing needed to judge whether intended benefits actually exist” (p. 325). The same warning can be given with the plethysmograph, which likewise raises many ethical questions if used with youth.

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The risk assessment (and risk management) tools we examined in our 2018 special issue article represent a spectrum of tools varying in construction, design, focus of the measure, and samples tested on. Not reviewed was a relatively new Canadian measure Violence Risk Scale: Youth Sexual Offender version (VRS: YSO, Rojas and Olver 2019), which assesses risk for sexual violence. Its primary roots are from frameworks used to assess convicted adult sex offenders given that “it drew heavily from the item content of the Violence Risk Scale–Sexual Offense Version (VRS-SO; Wong, Olver, Nicholaichuk, & Gordon, 2003-2017), developed for adult sexual offenders” (Rojas and Olver 2019, p. 5), and was compared to the J-SOAP-II, ERASOR, and J-SORRAT-II to assess concurrent validity. VRS-YSO was validated on a very small non-representative sample of 102 court-adjudicated youth referred for assessment and/or treatment in outpatient services and followed an average of 11.7 years in the community. Level of sexual violence that subjects engaged in did not appear to include seriously egregious sex crimes (i.e., torture, dismemberment, murder). Thus, VRO: YSO is not necessarily applicable to assessing the most dangerous sexually abusive youth “sexually violent” and/or “predatory sexually violent.” The nomenclature established by Miccio-Fonseca and Rasmussen (2014), empirically supported by cross-validation data from the MEGA♪ studies (Miccio-Fonseca 2018b), identified sexually violent and predatory sexually violent youth as two very rare subtypes, that is, anomalies among sexually abusive youth. The four calibrated risk levels of MEGA♪ include a very high risk level designed to make the fine distinctions necessary to assess the most egregious youth. Knight (2014) highlighted the usefulness of MEGA♪’s Antisocial Aggregate for assessing two aspects of antisociality: (a) “prior non-sexual offending and antisocial behavior in the home, school, and community” (p. 44) and (b) “callousness. . ..whether the youth disregards others” (p. 50). The New Paradigm of risk assessment involves customizing tools to the population assessed (i.e., males, females, children under 12, adolescents, youth with low intellectual functioning). Measures must be attuned and modified when they are employed in countries outside of their country of origin. Variables such as nuances in language, scholastic levels, ethnicity classifications, type of adjudications, type of weapons, and sentencing are to be taken into account. When duplicating a study of a measure, psychologists in other countries need to assure it is satisfactorily translated, is adapted for the cultural environment, and demonstrates the same original performance level (i.e., predictive accuracy). Overlooking anthropological factors and cultural nuances of a different language when designing risk tools can have adverse effects. For example, Generation Z (those born after 1996) is the first generation to be born into a completely digitized world. Risk assessment measures for this generation of youth must reflect modern times and match current language and technologies (e.g., digital terms, acronyms, social media platforms [Twitter, Facebook, Instagram, FaceTime, Snapchat]). Neglecting to integrate contemporary times when assessing risk likely adversely impacts findings.

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Risk and Protective Factors: Assessing Different Types of Sexually Abusive Youth (Adjudicated and Non-adjudicated) Sexually abusive youth are very heterogeneous and exhibit a range of risk and protective factors (dynamic and static). MEGA♪ was the first validated risk assessment tool for sexually abusive youth to incorporate a scale measuring protective factors that may mitigate risk. Including the Protective Scale in MEGA♪ allows risk and protective factors to be assessed simultaneously (Miccio-Fonseca 2009, 2010). It demonstrated significant findings in one of MEGA♪’s cross-validation studies (Miccio-Fonseca 2018a). The multiple cross-validation studies of MEGA♪ identified a constellation of protective factors interacting to mitigate risk for sexually abusive behaviors, evidencing that protective factors are specific to age and gender (MiccioFonseca 2018a). Incorporating protective factors in a risk assessment measure for youth was a substantial turning point in the evolution of risk assessment tools for sexually abusive youth, seen most recently in Kang et al.’s (2019) new tool, the TNPS. The New Paradigm of risk assessment presumes the risk measure implemented must be sensitive to within-group differences in age, gender, and intellectual functioning; one size does not fit all. The historical risk recidivism (predictive) tools (e.g., J-SOAP-II, ERASOR, JSORRAT) are primarily for assessing adjudicated male adolescents, thus inappropriate for assessing females, transgender youth, children under 12, and/or youth with low intellectual functioning. These populations each have distinctive characteristics needing to be considered when assessing risk.

Children Ages 4 to 12 Years Children ages 4–12 years are rarely reported to police even though many participate in serious sexually abusive behaviors (Miccio-Fonseca and Rasmussen 2014). Finkelhor, Ormrod, and Chaffin (2009) found that youth ages 6–12 constituted 16% of a sample of 13,471 juveniles identified by the US FBI National IncidentBased Reporting System (NIBRS) for committing sex crimes against minors in 2004. There were more females in this age group (14.6%) compared to 5.9% for the other ages (13–18). Compared to those of adolescents, sex crimes by the 6–12year-old children included less rape (11.0% vs. 26.4%), more sodomy (15.4% vs. 11.9%), and more sexual assault with object (7.2% vs. 4.2%). A 10-year prospective longitudinal study of 135 children ages 5–12 identified as having “sexual behavior problems” (Carpentier et al. 2006) found that less than 10% of the sample subsequently had sex offense arrests or child perpetration reports. Lussier, McGuish, Mathesius, Corrado, and Nadeau (2018) used a revised version of the Child Sexual Behavior Inventory (Friedrich et al. 1992) to follow a normative sample of 374 pre-schoolers from ages 3 to 8 and identified “four distinct sexual development trajectories” (p. 622). Children who showed “evidence of SIB [sexually intrusive behaviors] after school entry” (pp. 651–652, boys, 13% of the sample) were characterized by “a high rate increasing trajectory” (p. 651) of sexually

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intrusive behaviors, although the study did not find that any of the groups were more at risk for sexually abusive behavior in adolescence. MEGA♪ validation studies found that youth ages 4–12 (n ¼ 197 [validation study] and n ¼ 118 [cross-validation]) were at lower risk for coarse sexual improprieties and/or sexually abusive behaviors than youth ages 13–15 or 16–19 (Miccio-Fonseca 2009, 2010, 2013). Coarse sexual improprieties are behaviors that reflect an unsophisticated awareness of psychosexual conditions, environments, or social situations. Youth with coarse sexual improprieties engage in sexual behaviors that are crude, indecent, and outside the societal norms of propriety (e.g., crude sexual gestures, sexually suggestive comments, mooning, looking up skirts, a young child rubbing his or her genitals in public or trying to grab another’s genitals, a child looking over a stall in a public restroom) (Miccio-Fonseca 2010). Sexually abusive behaviors and improprieties fall along a coercion continuum of low, moderate, high, or very high (lethal) risk; this applies to sexually abusive youths who are either adjudicated or non-adjudicated (Miccio-Fonseca 2010). Two combined samples studies later completed on MEGA♪ consisted of (a) MEGA♪ validation and crossvalidation studies (N ¼ 3,901) and (b) combined cross-validation studies (N ¼ 2,717), providing the largest samples yet studied of sexually abusive youth under age 12 (n ¼ 592 and n ¼ 395, respectively). In the sample of 3,901, only 20 (3.5%) of 592 youth ages 4–12 scored at very high risk on the Risk Scale (MiccioFonseca 2018b, 2019). In the sample of 2,717, the 4–12-year-old age group had a higher percentage with low intellectual functioning (23%) than the total sample (19%) (Miccio-Fonseca 2019).

Sexually Abusive Youth with Low Intellectual Functioning Youth with low intellectual functioning (i.e., observable intellectual challenges) are challenging to study due to the “level of subjectivity regarding decisions whether an ‘offence’ has taken place and a conviction is pursued” (Griffin and Vettor 2012, p. 65). Gilby, Wolf, and Goldberg’s (1989) dated study hypothesized that the increased frequency of sexual behavior problems in their sample may have been due to staff providing more intensive monitoring, perhaps overestimating the incidence. Youth with low intellectual functioning often have neuropsychological problems (e.g., problems in attention and/or self-regulation, head injury, history of epilepsy, learning disabilities [Miccio-Fonseca and Rasmussen 2013]), variables that must be considered when designing risk assessment tools (Blasingame 2018; Karsten and Dempsey 2018). They also have multiple problems related to neglectful, chronically unstable family environments, including separation from parents (Miccio-Fonseca and Rasmussen 2013), and placement in foster care, often at an early age (Gilby et al. 1989). The MEGA♪ validation studies reported youth with low intellectual functioning (constituting approximately 19% of the samples) were significantly lower on the Protective Scale, perhaps pointing to these youth having limited resources combined with increased social isolation (Miccio-Fonseca 2009, 2010, 2013). These youth also had significantly higher Risk Scale scores for coarse sexual improprieties and/or

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sexually abusive behaviors, yet were significantly less likely to recidivate (MiccioFonseca and Rasmussen 2013). The two major combined cross-validation studies of MEGA♪ (N ¼ 3,901 N ¼ 2,717) found that youth with low intellectual functioning of borderline or below average showed similar patterns. These are the largest samples of youth with low intellectual functioning ever studied (n ¼ 746 and n ¼ 522, respectively) (Miccio-Fonseca and Rasmussen 2019). Blasingame (2018) included MEGA♪ in his review of risk assessment tools that can be used to assess “adolescents with intellectual disabilities (ID) who exhibit sexual behavior problems and/or sexually offending behaviors (SPOB)” (p. 1). Citing MEGA♪ as “the exception,” Karsten and Dempsey (2018) stated, “it is not standard practice to include instruments of intellectual and cognitive functioning in risk assessments” (p. 7).

Transgender Youth Transgender refers to a broad spectrum of people “who transiently or persistently identify with a gender different from their natal gender” (DSM-5, American Psychiatric Association [APA] 2013, p. 451). A literature search of academic databases (i.e., Psych INFO, Psych ARTICLES, MEDLINE, Academic Search Premier Criminal Justice Abstracts) yielded no information on transgender sexually abusive youth. Those conducting risk assessment need be more inclusive and include transgender youth as a distinct population. MEGA♪ combined cross-validation sample studies (N ¼ 2,717) included a small number (n ¼ 12) of transgender females (whose birth sex was male but identified as female), but no transgender males (whose birth sex was female but identify as male). The transgender females had a higher percentage of learning disabilities (42% compared to 31% for males and 25% for females) and more disciplinary problems in school. A higher percentage experienced physical abuse (58% compared to 43% for males and 40% females) (Miccio-Fonseca 2018c). More transgender females (41.7%) were youth with low intellectual functioning compared to the rest of the sample (18.8%) (Miccio-Fonseca and Rasmussen 2019).

Sexually Abusive Female Youth Sexually abusive females are in considerably smaller numbers than their male counterparts, presenting a notable challenge in creating a risk assessment tool, particularly since they have negligible recidivism rates and samples are typically less than 120 (Williams and Bierie 2015). Although female youth typically are less coercive than males, a few can be sexually violent and/or predatory sexually violent (Miccio-Fonseca and Rasmussen 2014). MEGA♪ studies consistently demonstrated that female youth are, in general, at lower risk for coarse sexual improprieties and/or sexually abusive behaviors than males regardless of age. Only 3.9% of females were assessed at very high risk in MEGA♪ combined validation and cross-validation studies (N ¼ 3,901) (Miccio-Fonseca 2018b). Protective and risk factors were

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empirically demonstrated to be gender and age specific (Miccio-Fonseca 2018a), pointing to distinct differences that females have from males. A more extensive review detailing differences between male and female sexually abusive youth is available in the special issue article on risk assessment in the Journal of Child Sexual Abuse, “Scientific Evolution of Clinical and Risk Assessment of Sexually Abusive Youth” (Miccio-Fonseca and Rasmussen 2018).

Sexually Abusive Youth Who Are Inconspicuous Those who engage in various atypical sexual improprieties and/or abuses with little to no empirical study are inconspicuous sexually abusive youth (e.g., Internet sexonly offenders, human sex traffickers and recruiters, and others). Mistakenly, professionals may easily think of them as being like other sexually abusive youth typically seen, not recognizing that engaging in sexually related practices and behaviors on the Internet are unconventional and idiosyncratic, making them distinctively different. Refinements of risk assessment measures include sensitivities to these yet unstudied sub-groups. Internet sex-only offenders comprise a possible sizeable but obscure sub-group of individuals (of all ages and genders). Their “compendium” is complicated by the significant lack of experimental descriptive research providing a complete picture of their risk and protective factors. The contemporary digital age has marvelous advantages (e.g., rapid dissemination of information, connecting with others on the other side of the planet in seconds) and considerable costs (i.e., adversaries meddling in democratic elections or hacking large companies and stealing personal information of customers). Youth readily take part in these new technologies. Distributing intimate and private material (i.e., nude selfies) has reached critical mass, prompting legislators, policy makers, attorneys, and judges to recognize that current laws are inadequate to deal with the sizeable changes and abuses occurring in the digital world. Over time, anthropological and sociological changes are internalized. As time goes on and records are kept, tracking users, topics, websites visited, and new laws implemented, a clearer picture of just who the “Internet sex-only offenders are” will emerge. At this point professionals have anecdotal reports of harmful consequences of sexually related offenses on the Internet (e.g., revenge porn, unwanted sharing of nude selfies, youth lured via the Internet to a meeting place that may include out-ofstate travel with an adult). The “Internet sex-only offenders” may turn out to be a characteristically different kind of sexually abusive individual with fastidious sexual proclivities differing appreciably from one another in age and gender, generational cohort, and anthropological and sociological variables. Early empirically supported impressions indicate Internet sex-only offenders (adult or adolescent) are a very heterogeneous group of individuals (Meridian et al. 2016). Conceivably research may demonstrate that these youth have more similarities than differences with regard to risk variables (e.g., separated from parents prior to age 16, victim of some kind of abuse, exposed to domestic violence, engaging in coarse sexual improprieties and/or

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sexually abusive behaviors prior to early adolescence), all findings seen in the extensive descriptive data gleaned through the MEGA♪ validation and cross-validation research now totaling close to 4,000 youth (Miccio-Fonseca 2009, 2010, 2013, 2018a, b). A slowly emerging small sub-group of sexually abusive youth consists of juvenile sex traffickers, who can be males, females, or transgender. The role of juveniles in sex trafficking can be hypothesized based on what is known about human sex trafficking in general. The juvenile sex trafficker is “a lower-level force that assists in the business (i.e., the recruitment and marketing)” (Miccio-Fonseca 2017, p. 8). Descriptions of these perpetrators come from courageous victims who come forward telling their stories (Polaris Project 2015). Detailed victim reports depict the perpetrators as excessively aggressive, often drug dealers, and some sexually violent and/ or predatory sexually violent (Miccio-Fonseca and Rasmussen 2014). A small percentage of juvenile sex traffickers are part of a “family business” and culture (Polaris Project 2012); some are victims as well as perpetrators (Miccio-Fonseca 2017).

Discussion All risk assessment tools have limitations, including the scientifically constructed tools (i.e., JSORRAT-II and MEGA♪). No risk assessment measure is 100% accurate. It is possible, however, to improve the measure’s accuracy through continued crossvalidation research and independent studies. At the root, accuracy reflects the methodology in which the tool is designed and created. To be precise and improve accuracy, creators/authors of risk assessment tools must adhere to the parameters of professional standards (AERA et al. 2014). Maintaining the best evidence-based practices is cardinal, more so when making critical determinations related to level of care of possible placements (i.e., removing a youth from their home environment and/or recommending intensive supervision and monitoring and/or detention/correctional detainment). Our review of risk assessment tools found there did not seem to be a consistent practice in methods of creating tools, possibly a major contributing factor for the contradictory, perplexing, and non-significant findings in many studies on risk assessment tools and youth (Miccio-Fonseca and Rasmussen 2018). Authors of tools at times neglect to follow some of the basic professional standards of practice (e.g., providing an accompanying manual for the tool to assist the User to know the parameters regarding the tool). Typically, a tool’s manual provides information as to application (i.e., gender, age, education level, and/or intellectual functioning of youth) and limits (e.g., not using a tool validated for males to assess females and/ or children under 12) and describes the scoring methods. The tool’s manual also provides instructions and explanation about the prerequisites of the measure as it relates to the User (i.e., Does it require professional experience? Must one be a licensed mental health professional? What training is required?). Specified in the measure’s manual are the operational definitions of terms. For example, if it is a risk

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recidivism (predictive) tool, operational definitions of the predictive variables would be provided (i.e., “sexual recidivism” [e.g., arrest, charge, adjudication, or accusation of repeated sexually abusive behaviors]). A manual standardizes how measures are used among professionals in the field, which is apt to result in definitive findings in the research. The focus in developing risk assessment tools is improving them through scientific methodology. Although risk recidivism (predictive) tools for youth are better than chance, they continue to need improved accuracy. In contrast, risk level assessment tools are calibrated for accuracy (according to age and gender), thus assuring prognostic utility. According to Caldwell (2016), “. . .predictive utility of sexual risk assessment methods used with juveniles should include a careful review of the calibration and performance characteristics of the method, and not the area under the curve (AUC) statistic alone” (p. 8). Barra, Bessler, Landolt, and Aebi (2018), citing Singh (2013), also pointed out “. . . no reliable measures for calibration are available to date for instruments without specific cut-off values” (p. 11). To date, the only risk assessment tools with cut-off scores for sexually abusive youth are JSORRAT-II and MEGA♪. Some sexual abuse cases are “active” for an extended period that can last for years and involve numerous juvenile court hearings, review hearings, probationary monitoring/supervision, and other actions. A tool’s capability to capture the youth’s risk and protective factors over time, according to age and gender, gives an individualized picture of the youth’s historical patterns related to risk level and protective factors. Legitimate concerns are expressed regarding using risk assessment tools on youth under age 12 years (e.g., imposing a depreciatory label). Professionals completing risk assessments on these younger youth may be disquieted that an assessment of “high risk” or “very high risk” may be something a youth can never overcome. However, there are a very few younger youths who engage in coercive sexually abusive behavior, making risk assessment appropriate for this age group. The largest study on sexually abusive youth of children under 12 (n ¼ 592, of a total N ¼ 3,901 youth ages 4–19) found that an exceptionally small number are dangerous and at very high risk (Miccio-Fonseca 2019). The best assessment method available is implementing a tool that in fact has been validated and cross-validated on this age group of youth and on females as well as males. Ethical practice recognizes that youth are constantly developing, growing, and changing. Employing tools with proficiency and repeating analysis over time on the youth’s risk level and protective factors according to their gender and age are invaluable for those cases in long-term placement or meeting requirements of 6-month court review hearings. Cases of sexually abusive youth are forensic in nature, meaning they involve judicial systems. Court systems require empirical grounding for the risk assessment tools implemented and intellectual honesty about the parameters of the tools used. Professionals need to be frank about the constraints of the tool implemented (e.g., lack of generalizability due to small samples) and not overstate a measure’s performance or its predictive validity. In reviewing the current measures for risk assessment related to sexually abusive youth (either adjudicated or non-adjudicated), we uncovered several deficiencies.

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Often ignored in risk assessments of sexually abusive youth are neuropsychological dynamics related to brain functioning. These may be risk factors for sexually abusive behavior, as well as non-sexual aggressive and violent offenses (Karsten and Dempsey 2018; Miccio-Fonseca and Rasmussen 2013, 2014). For example, the dated J-SOAP-II does not directly assess critical neuropsychological variables related to cognitive functioning (e.g., low intellectual functioning, problems focusing attention, learning disability). Instead, neuropsychological variables are related to impaired self-regulation (e.g., impulsivity, anger outbursts) and then incorporated with problematic behaviors (e.g., vandalism, truancy, fighting, theft, reckless driving) into the Impulsive, Antisocial Behavior scale (Prentky and Righthand 2003). In contrast, in the contemporary tool MEGA♪, impulsivity is considered a behavioral indicator of impaired executive functioning (i.e., a diagnostic criterion of attention deficits or anxiety/post-traumatic stress disorders), involving problems sustaining attention and regulating emotions. Impulsivity is assessed in MEGA♪ with other neuropsychological elements (e.g., low intellectual functioning, learning disabilities, attention problems) (Miccio-Fonseca 2009, 2010, 2013; Miccio-Fonseca and Rasmussen 2013). JSORRAT-II does not assess these variables, although it does include an item asking about history of placement in special education (Epperson and Ralston 2015). While there has been an evolution of risk measures, a sustaining set of complications still endure. Inculcating risk measures with embryonic roots to information partially drawn from samples of convicted adult male sex offenders seems a continual error in the field. This is evidenced by the fact that Kang, Prentky, Righthand, Worling, and co-authors’ present-day protocol and tool, the TNPS, still relied on J-SOAP-II and ERASOR as sources of items (Kang et al. 2019, see p. 159). Other difficulties include ignoring or being insensitive to subtle differences in culture and language; creating and testing potential measures on small, non-generalizable samples; and applying tools to females, transgender youth, children under 12, and youth with low intellectual functioning when they were not designed for those populations. The variance in predictive validity of J-SOAP-II, ERASOR, and JSORRAT-II has become a key concern, detailed elsewhere by other researchers of risk assessment tools (Fanniff and Letourneau 2012; Hempel et al. 2013), and reiterated in Caldwell’s (2019) call to cease using such tools with youth because “they do more harm than good” (Slide 45). There are many reasons for perplexing contradictory findings found in the literature related to risk assessment tools for sexually abusive youth. A prominent reason may be the varying definitions of “sexual recidivism” or “re-offense” in risk assessment studies. The variance in operational terms confuses the recidivism rate, thus muddling meta-analyses of risk assessment studies attempting to measure various aspects of “recidivism” (Caldwell 2019; Viljoen et al. 2012). Not all sexually abusive youth are identified; sex crimes are known to be underreported. In some cases, even if reported, the wheels of the law enforcement and judicial systems are not put into motion (i.e., youth is not investigated, or arrested, nor charged, nor adjudicated; youth may be too young, victims may recant, etc.). A charge for a sex crime implies guilt; adjudication confirms it. Defining recidivism as an arrest or

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charge allows for reasonable challenges to some youth identified as recidivists, since they may in fact have been innocent. Risk assessment studies typically do not inform the reader that a sample of recidivists may include innocent individuals. It is understandable to use arrests and/or charges as indicators of re-offense. However, including an arrest and/or a charge as “recidivism” likely inflates realities of the situation and may skew the data toward a higher risk level. Often the adjudication status of a sample is not specified. This confounds the overall picture of the sexually abusive youth, who is not clearly described in the studies. Significant differences exist between youth who are dealt with through the juvenile justice system and those who are dependents of the court or youth in the community who were arrested but not charged nor detained. It is imperative that researchers of assessment tools provide the basic details of the construction sample (e.g., adjudication status, gender, age, intellectual functioning) and candor on limitations of the tool. Contradictory findings on predictive utility of risk assessment tools may be due to differences in the judiciary status of different samples and nonstandardization of definitions of recidivism. Research studies include non-adjudicated youth with a few law enforcement contacts and/or youth with no law enforcement contact (i.e., dependent youth placed out of home placement) (Miccio-Fonseca 2009, 2010, 2013; Prentky et al. 2010); these variables are to be taken into account in research studies. Assessment tools constructed on adjudicated male youth are often assumed to be applicable to non-adjudicated youth, or those without law enforcement involvement, or to female youth and children under 12 years, when there is limited empirical evidence justifying their use with those populations. Speaking to this lack of specificity, we proposed a template for differentiating sexually abusive youth “according to ad hoc categories (related to sex crimes or nonsexual crimes committed)” (Miccio-Fonseca and Rasmussen 2014, p. 3). Categories include: “(a) non-delinquent youth, (b) non-adjudicated delinquent youth, (c) nonadjudicated sexually abusive youth, (d) adjudicated sex offenders whose crime history is predominantly composed of sex crimes and/or sexually related sex crimes, and (e) adjudicated non-sexual offenders whose crime history is predominantly composed of non-sexual crimes” (p. 3). Non-delinquent youth and non-adjudicated youth have had no contact with law enforcement, while youth in the other categories “have come to the attention of law enforcement in some fashion and/or have gone through proceedings in juvenile or adult court systems” (p. 3). This template is offered as a guidepost to make research studies more definitive in operationally defining the sample studied.

Key Points 1. Empirical findings are demonstrating refinement in risk assessment tools for sexually abusive youth. 2. There is a call for ceasing the adoption of adult risk assessment paradigms on youth (i.e., implementing risk recidivism [predictive] tools). 3. New risk assessment tools are calibrated and sensitive to age and gender.

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4. The twenty-first century risk assessment tools are multidimensional addressing various domains related to the youth that are synchronistic.

Summary and Conclusion The New Paradigm of risk assessment tools calls for intricate, developmentally and gender-sensitive measures that more accurately assess (calibrated) risk level, demonstrating a more precise, comprehensive approach. At this point in time, the New Paradigm is only represented by MEGA♪. This will likely change as professionals respond to Caldwell’s (2019) call to cease using risk recidivism (predictive) tools and as risk assessment researchers create new tools. Possible evidence of the New Paradigm taking root is the new protocol and tool that Kang, Prentky, Righthand, Worling, and their co-authors (2019) have created. Their “new protocol” seems to follow many aspects of the MEGA♪ template. These similarities are as follows: (a) assesses risk and protective factors simultaneously, (b) uses age groups, (c) considers gender, (d) moves away from risk prediction assessments, (e) includes an outcome measure, (f) has a fourth level of “concern” (risk), (g) computerizes the measure, (h) computerizes the scoring, and (i) computerizes the generated report. Although Kang, Prentky, Righthand, Worling, and their co-authors may have incorporated many of the innovative features of MEGA♪, the tools sharply differ in their foundation. MEGA♪ is anchored in empirical research on youth, while Kang et al.’s protocol is still infused with the adult risk assessment model. Also, multiple deficiencies in the methodology of Kang et al.’s pilot study to validate their new tool erode the contribution the tool may make to the field (MiccioFonseca 2020). Continued refinements in risk assessment measures for youth need to focus on creating tools that, like MEGA♪, are multidimensional and do more than just assess risk. When rigorous professional standards in the scientific study of risk assessment are adhered to (i.e., large sample sizes; sensitivities to age groups, genders, and intellectual capacities), the prognostic utility of risk measures is vastly improved. Refining precision in assessment measures assists in the judicious allocation of resources, benefitting youths, their families, communities, the juvenile justice system, the child welfare and mental health systems, and society at large. When measures fail to meet the basic parameters of professional standards in psychometric measures or research (AERA et al. 2014), the risk for coarse sexual improprieties and/or sexually abusive behaviors may be overestimated. Profound adverse ramifications on youth and their families are then possible, including inappropriate placement outside their homes. Conversely, risk may be underestimated, compromising community safety and potentially resulting in additional victims. As this chapter goes to press, the world is confronting a pandemic of the coronavirus, leaving humanity with monumental sociological and anthropological changes likely to provoke innumerable transformations upon humanity globally. In the United States where the number of deaths is sharply rising, as in other countries, restrictions have been imposed on citizens (i.e., social distancing, staying home).

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Families are in close proximity with each other, perhaps for some, resulting in becoming more intimate in their interactions with one another. The imposed closeness may have surprising manifestations of lower recidivism rates (which are dynamic) for sexually abusive individuals. That is, the current cultural world theme is “We are in this together.” They may feel for the first time important to be included as “part of the family” and citizens who are part of society.

Cross-References ▶ Girls in Juvenile Justice ▶ Sex and Labor Trafficking: Trauma-Informed Themes Toward a Social Justice Approach ▶ Sexual Abuse of Children ▶ The Juvenile Justice Response to Violence

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The Commercial Sexual Exploitation of Children

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Current Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Sex Trafficking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Pornography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sex Tourism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Legislative Response to CSEC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Victim Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Relationship Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Family Conflict . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Societal Pressures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Societal Norms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gang Involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Societal Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lack of Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sexualization of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poverty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Effects of CSEC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Offender Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Sex Trafficking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Pornography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Sex Tourism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cultural Considerations for Prevention and Intervention of CSEC . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. J. Williams (*) · C. Lim · V. Trull · M. Higgins School of Social Work, The University of Alabama, Tuscaloosa, AL, USA e-mail: [email protected]; [email protected]; [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_182

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Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 927 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 927

Abstract

The commercial sexual exploitation of children (CSEC) conceptually encompasses any form of abuse that exploits children in a sexual nature, including child sex trafficking, child pornography, and sex tourism. This chapter will begin by discussing the organized crime model fueling the global CSEC crisis and theories aimed at the disruption of this enterprise. This will be followed by a review of the state of the literature regarding the historical context, definitions, and victim and offender characteristics of child sex trafficking, child pornography, and sex tourism. The chapter will conclude with a discussion of the role of the family and cultural considerations including race, gender, sexual orientation, and socioeconomic status in prevention and intervention efforts to end the exploitation of children. Keywords

Child sex trafficking · CSEC · Sexual exploitation · Human trafficking · Sex tourism · Child pornography

Introduction The commercial sexual exploitation of children (CSEC) is a growing issue in the fight for the protection of children. This particular type of abuse is a dangerous amalgamation of sexual abuse and organized crime. The Stockholm Declaration and Agenda for Action of 1996 defined CSEC as sexual abuse by an adult and remuneration in cash or kind to the child or a third person or persons. CSEC conceptually encompasses any form of abuse that exploits children in a sexual nature, including child trafficking, pornography, and sex tourism. The Institute of Medicine (2013) described CSEC as a range of sexual crimes that involve the exploitation of children for financial or other gain. The range of crimes included: • Recruiting, enticing, harboring, transporting, providing, obtaining, and/or maintaining (acts that constitute trafficking) a minor for the purpose of sexual exploitation: – Exploiting a minor through prostitution – Exploiting a minor through survival sex (exchanging sex/sexual acts for money or something of value [e.g., shelter, food, drugs]) • Using a minor in pornography: – Exploiting a minor through sex tourism, mail order bride trade, and early marriage – Exploiting a minor by having her or him perform in sexual venues (e.g., peep shows or strip clubs)

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Due to the broad nature of CSEC, the extreme variation in definitions, legislation, policies and practices, general underreporting, and difficulty identifying victims and perpetrators, reliable national estimates of CSEC are difficult to ascertain. In the 2013 report, the Institute of Medicine concluded that there were “no reliable estimates of the incidence or prevalence of commercial sexual exploitation and sex trafficking of minors in the United States” (p. 73). Global health and service organizations have attempted to provide international estimates for the purposes of policy and awareness. For example, the International Labour Organization estimates that approximately 1.2 million children are victims of forced sexual exploitation (Forced Labor. . . 2017). These estimates however should be interpreted cautiously given the methodological difficulty in counting incidence and prevalence of child sexual exploitation (Institute of Medicine 2013). When working to address the issues related to child sex trafficking, it is important to understand the economic motivations of the perpetrators of these crimes. Socioeconomic status of the family is relevant, as selling the child may help the family cover their own personal expenses. However, familial trafficking is more often related to funding other illicit activities and is inexcusable regardless of the purpose. Furthermore, perpetrators engage in child sex trafficking because there is someone willing to pay them money for this. Therefore, to solve this problem, it is equally important to consider treatment and interventions for the perpetrators, as well as effective law enforcement actions in order to address and reduce the financial incentives for individuals to traffick children.

Current Definitions Child Sex Trafficking In 2004, the International Labour Organization (ILO) estimated that every year 1.2 million children are victims of human trafficking worldwide. Within the United States, Estes and Weiner (2001) estimated that there are approximately 200,000– 300,000 child victims of human trafficking each year. The Trafficking Victims Protection Act (TVPA) of 2000 was the first comprehensive law regarding human trafficking in the United States. TVPA defines sex trafficking as the: recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purposes of a commercial sex act, in which the commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age.

The United Nations Convention Against Transnational Organized Crime’s Palermo Protocol defined child trafficking as the act of recruitment, transportation, transfer, harboring, or receipt of a child for the purpose of exploitation regardless of the use of force, deception, or coercion. It is the first global and legally binding instrument with an agreed upon definition of trafficking in persons.

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Child Pornography There are key terms in laws and discussions related to child pornography that aid in understanding the issue. Child pornography itself is federally defined as any visual depiction, including any photography, film, video, picture, or computer or computergenerated image or picture, whether made or produced by electronic, mechanical, or other means, of sexually explicit conduct involving a minor or person who cannot be distinguished from a minor, or is made from images of an identifiable minor. A minor, in this case, is someone under the age of 18. While states have varying ages of majority and consent, the federal standard in relation to child pornography is age 18 (Seigfried-Spellar et al. 2012). There is a growing movement to change the terminology from child pornography to child sex abuse images, due to the nonconsensual nature of the crime, and the consensual implication of the term “pornography.” While this is an important and necessary change, references here remain to child pornography due to the current language used in the applicable laws. Three terms are used to describe the content of pornographic imagery which helps to determine whether images are considered illegal. Indecent indicates something that is against the common moral standard or good behavior (Cohen 2009; USLegal n.d.). Imagery that is considered indecent is not illegal and is generally protected by the First Amendment, with some exceptions for time or place. Obscene images are those that go beyond being simply indecent and are deemed illegal based on the three-pronged scrutiny of the Miller test, which requires three conditions be met: • Whether the average person, applying contemporary community standards, would find that the work, taken as a whole, appeals to prurient interest • Whether the work depicts or describes, in a patently offensive way, sexual conduct or excretory functions specifically defined by applicable state law • Whether the work, taken as a whole, lacks serious literary, artistic, political, or scientific value (Cohen 2009; USLegal n.d.) Any sexual imagery involving a child is deemed to be obscene based on current law. Lascivious is defined as “tending to excite lust” (USLegal n.d.). In the context of child pornography, lascivious imagery is that which involves a child potentially clothed but displayed in such a way that a person with a sexual interest in children could find sexual gratification. This type of imagery has also been deemed obscene and illegal.

Sex Tourism Some studies have found discussions about sex tourism dating back as far as the 1700s with Lady Mary Wortley Montagu and the late 1800s with Margaret Fontaine and Lady Jane Digby (Bauer 2014). However, as child protection efforts strengthened in the United States, sex tourism came of age in the 1900s when technology and increased disposable income made travel available to the masses. Countries with

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high rates of poverty and favorable climates became destination locations where pedophiles and other sexual predators found hospitable environments to victimize children. Places like Southeast Asia, Africa, and the Caribbean quickly became hotbeds for child sex tourism (Estes 2014; Jones 2006; Omondi 2016). Sex tourism occurs when someone travels, often from their country to another, for the primary purpose of engaging in romantic and/or sexual activities with “others” in the destination country. Making distinctions between child sex tourism, human trafficking, romance tourism, and romantic safaris can be difficult because at times the characteristics of victims and offenders can vary greatly, and in some situations the distinctions could be quite nuanced. “In short, the complexities of socio-economic and gender relationships give rise to a series of alternative patterns that while there is little doubt of the trafficking of women, there also exist alternative forms of sex work” (Omondi 2016). When considering the category of “romance tourism” or “romantic safaris,” the analysis of push/pull factors, contributing and mitigating factors, or even the moral and legal status of those involved can be complex. Omondi conducted a 12-month immersive research process considering the sex tourism industry on the Mombasa coastline which indicated a “complex patterns of deceit, of human frailties, of affection and performances that take advantages of both the main actors involved in the performance of sex work, and where both win and lose. In doing so, it does not reduce these complexities to sets of abstracted causal relationships, but reports phenomena as existing side by side, sometimes separately, and sometimes entwined, based on a mixture of psychological, social and economic needs and/or aspirations” (Omondi 2016). Moreover, sex tourism is distinct from sex while traveling. “In this category, sex was described as an important motivator for the tourist experience, explained as related to relaxation, pleasure, quality time with one’s partner, and detachment from routine” (Berdychevsky 2012). Many travelers expect that their sexual activity will increase while on holiday. They may experience multiple sexual partners known or unknown to them previously and who may be from their destination spot or may be fellow travelers (Ward-Pelar 2010). The distinctions between child sex tourism, human trafficking, romance tourism, and romantic safaris therefore might be nuanced when the person being objectified is an adult; however, when the person is a minor, that activity is always abusive and exploitative. A child who is sexually exploited is in need of protection and restorative services.

Legislative Response to CSEC The history of CSEC evolved from the history of child abuse and neglect. Writings as early as 900 AD mention intentional harm of children by caregivers and other adults. In the United States, the first child protection agencies were formed in the late 1800s. Prior to these organizations, sporadic criminal prosecution and removal of children from unfit parents were the primary mechanisms of response to egregious

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abuse (Myers 2008). The formation of non-governmental child protection agencies happened within the larger backdrop of antislavery and human rights advocacy efforts worldwide. In London, the National Vigilance Association (NVA) was formed in 1885 to privately prosecute infringements of the Criminal Law Act (Cree 2008). The major provisions related to CSEC included: • • • •

Making it illegal to procure a woman under 21 for prostitution Raising the age of sexual consent from 13 to 16 Making it illegal to detain a woman or a girl for the purposes of unlawful sex Making it illegal to manage premises used as a brothel

In the early twentieth century, child advocates began to call for governmental intervention in the protection of children. This shift coincided with the formation of juvenile courts in 1899 and the uprising of “state departments of welfare, social services, health and labor” (Myers 2008, p. 452). During this time, the international community began to respond to the issues of the commercial sexual exploitation of children. In 1904, France spearheaded the International Agreement for the Suppression of the White Slave Traffic. This agreement involved requiring staff in railway stations and ports of embarkation to watch for women and girls involved in prostitution (Allain 2018). In the United States, the first anti-trafficking Act was the Page Act of 1875. This law prohibited the importation of unfree laborers and women brought for “immoral purposes” but was enforced primarily against Chinese immigrants. Legislated amid the spread of anti-Chinese fervor from the west coast to the rest of the United States, this law was used as an early effort to restrict Asian immigration without categorically restricting Asian immigration on the basis of race and instead restricting select categories of persons whose labor was perceived as immoral or coerced (Page Law (1875) 2020). In an attempt to adequately address the issue of human trafficking, new legislation was passed under the Mann Act (1910 amended in 1917). The Mann Act was enacted to address forced prostitution and the transportation of women or girls across state lines (Women at Risk International 2012). In practice, the Mann Act was often used to criminalize consensual sexual activity and was not seen as specifically targeted to the welfare of children. Child welfare historians often cite the creation of the Children’s Bureau in 1912 and the Sheppard-Towner Act as the first federal intervention efforts in child protection. The Children’s Bureau and the Sheppard-Towner Act provided federal financial support for mothers and children. Later, in 1935 the Social Security Act included Aid to Dependent Children and a provision that authorized the Children’s Bureau to assist in the establishing public welfare agencies for the “protection and care of homeless, dependent and neglected children and children in danger of becoming delinquent.” It was not until the 1970s that major federal legislation was enacted to specifically protect children against CSEC in the United States. The Child Abuse Prevention Act passed in 1974 authorized federal funding to respond to child abuse and neglect. The Protection of Children Against Sexual Exploitation Act of 1977 was the first federal

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law to specifically address child pornography in the United States (Seigfried-Spellar et al. 2012). Under this law, the production or commercial distribution of sexual images of a child age 16 or younger were deemed sexual exploitation of a child. The Act defined “sexually explicit conduct” to include “actual or simulated sexual intercourse, bestiality, masturbation, or sado-masochistic abuse, or lewd exhibition of the genitals or pubic area.” Further, the Act made it illegal to transport a child under the age of 16 for the purpose of sexual exploitation, including for the purpose of commercial sex (Seigfried-Spellar et al. 2012). Also in the late 1970s, the Mann Act was amended to protect male and female minors from sexual exploitation, providing actual federal protection for abused and exploited youth in the United States. Child pornography has a distinct legal history that has largely been influenced by arguments around first amendment rights and technological advances. The Child Protection Act of 1984 redefined the applicable age to be anyone under age 18 and codified at the federal level that child pornography was inherently obscene and therefore not protected by the First Amendment. The Child Protection Act also removed the requirement that distribution must be for commercial purposes, so even trading images was therefore illegal, whether or not money changed hands. Production of child pornography also received added attention, as the need to prove a connection between victim and photographer was removed – even reproducing existing images was now considered production. Increased sentencing guidelines, criminal and civil forfeiture, and electronic surveillance allowances (wiretapping) were also included in the Child Protection Act, greatly strengthening the federal government’s stance and abilities in fighting the growing child pornography problem. Perhaps most significantly, the requirement that images be “for the purpose of sexual stimulation” was removed, and “lascivious exhibition” was added to the definition of child pornography. This broadened the scope of the definition to include the possibility of images that may not depict nudity but might involve restraint, humiliation, or suggestive posing (Weiss 1985). The mid-1980s brought about a new kind of revolution – this time, a technological one. The advent and rise of the Internet created a whole new world to be created and explored and unfortunately, a new place to carry out criminal activity. By the mid-1980s, Congress recognized that child pornography had found a new home among the technologically savvy deviant population. The Child Protection and Obscenity Enforcement Act of 1988 required records to be kept proving age of participants in sexually explicit material at the time of production. The role of “secondary producer” was also defined, meaning anyone who reproduces or electronically distributes pornographic material. By this definition, anyone distributing pornographic material must have or know where to access records of the ages of performers for any images or videos they distribute. The Act expressly included electronic distribution via use of computer site or services. Therefore, anyone sharing pornographic images online was responsible for record keeping to prove all performers were at least 18 years of age at the time of production. This required that companies creating pornographic material had to include a notation in the work

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regarding record keeping, and those files must be accessible for 5 years after the company closed (Seigfried-Spellar et al. 2012). By the 1990s, it was apparent that the laws passed in the 1980s would not be sufficient to address the challenges introduced by the Internet and the digital age. In response, the Child Pornography Prevention Act of 1996 (CPPA) was passed, changing the definition of child pornography to take into account computer-generated images (Sternberg 2001). Under this Act, the definition of child pornography included any visual depiction, including any photograph, film, video, picture, or computer or computer-generated image or picture, whether made or produced by electronic, mechanical, or other means of sexually explicit conduct, where: (A) The production of such visual depiction involves the use of a minor engaging in sexually explicit conduct (B) Such visual depiction is, or appears to be, of a minor engaging in sexually explicit conduct (C) Such visual depiction has been created, adapted, or modified to appear that an identifiable minor is engaging in sexually explicit conduct (D) Such visual depiction is advertised, promoted, presented, described, or distributed in such a manner that conveys the impression that the material is or contains a visual depiction of a minor engaging in sexually explicit conduct (Seigfried-Spellar et al. 2012) The CPPA faced immediate scrutiny on the basis of First Amendment violations. Appellate courts saw multiple cases prior to the argument being heard by the US Supreme Court in Ashcroft v. Free Speech Coalition in 2002, which challenged the CPPA for being overly broad and therefore unconstitutional. This resulted in virtual child pornography being deemed protected by the First Amendment. In 2003, the PROTECT Act was passed: Prosecutorial Remedies and Other Tools to end the Exploitation of Children Today. This placed the burden of proof on the defense that child pornography images were created virtually and did not involve any actual photos of children. The Effective Child Pornography Prosecution Act of 2007 changed the wording of 18 § 2251 from “use of a computer” to “use of any means or facility or interstate or foreign commerce” regarding distribution of child pornography. A second title in the same bill made it illegal to import child pornography to the United States and added an “intent to view” clarification for possession of child pornography accessed via the Internet. The landmark legislation in the United States was the Victims of Trafficking and Violence Protection Act (TVPA) of 2000. This act created prosecutorial tools and established prevention measures to combat human trafficking. It also created the Office to Monitor and Combat Trafficking which publishes the Trafficking in Persons (TIP) Report annually to describe and rank each countries’ efforts to comply with the agreed-upon international standards of human rights. In 2008, another PROTECT Act was passed, utilizing the same acronym for a new but related purpose. The Providing Resources, Officers, and Technology to Eradicate Cyber Threats to Our Children Act of 2008 created a variety of resources to address Internet Crimes Against Children and added a prohibition against the

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broadcasting or viewing a broadcast of pornographic sexual abuse images of children. In addition, language was strengthened to expressly prohibit the adaptation of identifiable images of children for the use of creating pornographic imagery (Seigfried-Spellar et al. 2012). The Child Protection Act of 2012 amended prior laws to give special consideration for the age of the victim in child pornography cases. Specifically, cases involving pre-pubescent victims or those who had not reached 12 years of age at the time of the offense faced harsher sentencing guidelines, doubling the maximum sentencing from 10 to 20 years. This Act also provided protection against harassment for victims and witnesses who are minors in any federal criminal cases (Seigfried-Spellar et al. 2012). In 2017 two Acts were enacted that provide much needed prosecutorial directives to address those companies and individuals who support and facilitate sex trafficking online. The Fight Online Sex Trafficking (FOSTA) Act and Stop Enabling Sex Traffickers (SESTA) Act of 2017 were used to effectively prosecute a historic case against Backpage. Confronting Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States by Clayton, Ellen Wright, et al. Reproduced with permission of National Academies Press in the format Book via Copyright Clearance Center (Fig. 1).

Victim Characteristics There are multi-systemic factors that contribute to victimization. Finigan-Carr et al., (2019) illustrated these multi-systemic risk factors of CSEC using an ecological model (see Fig. 1). This model described multi-systemic risk factors of CSEC in order of

Fig. 1 Ecological model adapted to illustrate the possible risk factors for commercial sexual exploitation and sex trafficking of minors. (Note: LGBT ¼ lesbian, gay, bisexual, or transgender)

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increasing systemic complexity. Individual factors including history of abuse, homelessness, and runaway status are consistently reported in the literature. Varma et al. (2015) found that child victims of sex trafficking are more likely to have had experiences with violence, substance use, running away from home, and involvement with child protective services and/or law enforcement. These youth run away from home to escape abuse or neglect or have been expelled from the home, some due to behavior problems or parental conflict over sexual orientation or gender identity (Gibbs et al. 2015). These youth are often lured into sexual exploitation by engaging in “survival sex” and trading sex for shelter, food, clothing, or drugs. Additional demographic variables such as race and gender are also consistent risk factors for CSEC victimization (Finigan-Carr et al. 2019). The US Department of Justice collects victimization data through the National Incident-Based Reporting System (NIBRS). In 2004, a report was issued detailing crime statistics from 1997 to 2000 which found 62% of victims were female and 38% male: 59% teens (12–17 years), 28% school age (6–11 years), and 13% preschool age (under 5 years), and 25% were related to their offender (Finkelhor and Ormrod 2014). The Internet Watch Foundation assesses content found across the internet, reviewing a new page every 4 minutes. According to their report, 86% of victims pictured were girls, 7% boys, and 5% involved both boys and girls. 43% were teenagers (appearing to be between 11 and 15 years of age), 55% were under age 10, and 2% were age 2 or under (Internet Watch Foundation 2017). Quayle and Jones (2011) analyzed nearly 25,000 images and found 95% of victims to be white, 2% black, 1% Asian, and 2% Hispanic. Some studies indicate that race plays a significant role in sex tourism. Some point out that victims of human trafficking are often people of color being exploited by Europeans or westerners. They indicate that sex tourism is all about racism as it thrives on the eroticization of the cultural “other” since the tourists seek the services of prostitutes whose nationality, race, or class status are different from their own (Omondi 2016). This is found in the Caribbean and South America where westerners often seek out brown and black sex workers for an “exotic” sexual encounter. In other regions such as Southeast Asia predominately European males engage in sex tourism with young girls from those destination countries (Montgomery 2008). Some brothels however cater to specific ethnic groups. It is common to find in Cambodia or the Philippines establishments that only allow Korean men in their brothel. This might be for logistical reasons such as conducting business in only one language, but it is likely also a means of protecting the traffickers from criminal investigation.

Relationship Factors Family Conflict Family conflict can be defined as a struggle or a disagreement between parents, parent and child, or other members of a family. Although any child can become a victim of trafficking, living in a family with dysfunctions such as parental drug/

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alcohol abuse, parental mental illness, violence, single parent homes, absent fathers, and maltreatment significantly increases the risk. In a study conducted in the United States, 91% of the girls had experienced abuse in their home, 77% were previously involved with child protective services, and more than half had been in foster care (Rafferty 2016). Poverty within the family also creates stress that can lead to violence and neglect. Poverty is also one of the leading predictors of family involvement in trafficking through familial trafficking. It is estimated that between 450,000 and 2.8 million American children and teens run away or are thrown away each year, with the majority of these coming from homes where significant family conflict is present. A study of domestic minor sex trafficking across 10 cities in the United States, involving interviews with 297 victims, found that family played a significant role in the trafficking process. Family members were found to exchange sex with their child for goods or money in all ten locations (Smith et al. 2009). Family risk factors also need to be viewed in terms of extreme poverty, cultural factors, and prevailing social, cultural, and gender norms (Rafferty 2016). There is a pattern associated with trafficking vulnerabilities that can be traced to internal factors such as an individual’s own relative capacity to absorb/handle stress during such encounters, their low economic status, broken family background, little to no emotional support, a history of abuse, etc. (Loomba 2017). These vulnerabilities create an atmosphere where children are easily lured into trafficking with the promise of safety, protection, security, and basic needs being met (Cole 2018). Traffickers attempt to identify gaps caused by family dysfunction or sexual abuse to strategically provide safety, security, love, and belonging to establish a trauma bond, thereby keeping the child vulnerable to the trafficker (Rafferty 2016).

Community Factors Societal Pressures The focus society places on wealth, perfection, body image, and social status cause many adolescents to succumb to social and peer pressure. Social media has taken a forefront in setting expectations and enticing us to portray perfect lives. Three main factors lead youth to disclose personal information online: peer pressure, interface design, and signaling (Agosto and Abbas 2017). As youth are pressured to share more personal information, they become more vulnerable to human traffickers. The pressure to conform creates an internal conflict between wanting to avoid something undesirable and wanting to please someone and accepting it (Murray et al. 2015). Many times, a significant other will encourage the victim to rethink their attitude toward the act and reframing the symbolism of the action. This can be seen in the “Romeo” pimp scenario. A pimp will entice the victim with gifts, affection, and understanding and then pressure them into trafficking as a means of repaying or making them happy. When she complies with the requests, the “boyfriend” frames her as being loyal and that she should be proud (Murray et al. 2015).

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Another form of pressure is one of debt. Pimps may use kindness, compassion, or gifts such as cash, food, clothes, shelter, or drugs to make the child or teen feel grateful and indebted to the pimp. They may also make promises of modeling, acting, or making money quickly and pressure them to make a quick decision, creating a sort of debt bond with victims by forcing them to continue to make money to pay off a debt that is unachievable and unrealistic (Diaz et al. 2014). All of these types of pressure can be seen through the “push/pull” lens. The push factors are poverty/economic imbalance and lack of opportunities, and conflict with the “pull” factors being demand for cheap labor or provisional sex services, improved social position, and expectation of employment. “The theory of push and pull factors explain some of the roots of trafficking, although the core of modern slavery should be looked and connected with the one of trafficking in slaves (Stanojoska et al. 2012).”

Societal Norms Communities create and institute their own unique expectations of social norms. The social norms you will find in a wealthy, highly religious community will vary from those of a poor community with no shared cultural or religious beliefs. The impact these informal controls have on youth can contribute to CSEC risk factors (National Research Council 2013). For example, if a community holds strong religious beliefs that sex is an act restricted to marriage, the community is more likely to be restrictive toward sexual behaviors and enforce strict boundaries for their youth. A community that has an active and visible commercial sex presence is less likely to teach children that these behaviors are unhealthy or unsafe. When a community fails to control violence against women, male sexual conquest, and other forms of subjugation of women, they signal to youth that these behaviors are acceptable and increase the risk of CSEC to their children, and especially to their girls (National Research Council 2013). Boundaries instill a learned control in children and adolescents that enable them to more readily identify when someone is violating said boundary. Children who have not been taught these limitations are at an increased risk of sexual exploitation. Social norms exist beyond the bounds of a community as well. Social networks, which may exist within or outside of a formal community, can carry great influence with children and adolescents. If a teenager is around other teens who are being sexually exploited, the behavior can become normalized, limiting their ability to recognize the victimization of themselves or their peers (Hayes and Unwin 2016). This may occur in school, at camps or events, or even online.

Gang Involvement While it is common knowledge that gangs are heavily involved in crime, including drug trafficking, robbery, assault, and murder, little attention is paid to their involvement in commercial sex trafficking. There are approximately 20,000 gangs in the United States. The vast majority of gang members are male, though there are a few female-only gangs.

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Generally, women who become involved with gangs are connected through a male member or are “property” of the gang, rather than being a member (Lederer 2011). Gangs recruit girls for the purpose of sex trafficking through “Romeo pimps,” leading the girls to believe that they are in a loving relationship with the gang member, who then manipulates them into commercial sex acts. Once involved, girls are controlled by their traffickers either through drugs, which they may “work” to obtain from the gang, or force and violence. Much like the gang members themselves, once a girl is involved with a gang, she is not allowed to leave. As with all forms of sex trafficking, the profits come easier than in drug trafficking due to the gang’s ability to resell the same product repeatedly (Lederer 2011). Girls’ status within gangs is often related to their sexual availability to the male members of the gang as well (Hayes and Unwin 2016). Gang members expect to not only profit financially from the exploitation of girls but also to have girls readily available to themselves for their own sexual interests. Many of the girls who become involved with gangs have been sexually abused previously, making it all that much easier to manipulate the girls into providing both commercial sex acts and sexual availability for the gang members (Lederer 2011).

Societal Factors Lack of Awareness The lack of human trafficking awareness and training in the industries and professions that engage with victims of human trafficking, oftentimes unknowingly, is a global issue. The 2016 Global Study on Sexual Exploitation of Children in Travel and Tourism found a significant lack of training and awareness among all of the 20 Middle East and North African (MENA) countries as well as many Pacific and Asian counties (Hawke and Raphael 2016). The problem of insufficient training and awareness is likewise an issue in Europe and the Americas. Creating awareness disrupts the system of push and pull factors that creates vulnerabilities for victims of human trafficking, it obviates the deterrents for consumers of human trafficking, and it emboldens the efforts of exploitation from the traffickers. Awareness and training help prevent human trafficking and help law enforcement and public health professionals understand how to identify victims of human trafficking (Taylor 2018). Training for first responders and others who provide services to victims of human trafficking is most effective when it addresses the issue from a trauma-informed and victim-focused perspective. Best practice is to ensure that the voice of survivors of human trafficking influences the content of the training. The US Advisory Council on Human Trafficking indicated in their 2016 annual report the need for more awareness content for educators, law enforcement, and social service providers. The report additionally indicates the benefit of including the voice of survivors of human trafficking in awareness efforts (US Department of State 2018). Including the experience and perspectives of survivors is instructive in the creation of effective best practices.

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The voice of survivors in the creation of preventative efforts is essential in both public policy and legislation. Legislation may be a deterrent to some offenders who purchase sex from minors or adult victims of human trafficking. However, some research has indicated that creating awareness among sex buyers of the nature and effects of human trafficking in the sex industry could influence them to avoid those activities (Matthews 2018). When potential consumers understand the nature of human trafficking, they may be less likely to participate in human trafficking consumption.

Sexualization of Children Research conducted from an America university and two universities in Madrid, Spain, analyzed 193 pages from fashion magazines containing 414 images of children to determine if those images objectified children. Multiple factors were used to determine the level of exploitation exemplified in each image including the postures and gestures of the children, highlighted or dyed hair, clothing and accessories, and makeup and hairstyles. The study concluded that 88% of the children in those images were sexualized (Rodriguez et al. 2016). Some studies have tried to move away from terms like the “eroticizing” or “sexualization” of children with more understated terms like the “adultification” of children (Rush and La Nauze 2006; Trekels et al. 2018). This trend minimizes the harm inflicted on children from these objectifying images, videos, and songs and makes the objectification of children normative. However, the result of such images can impair the cognitive abilities of children, create body dissatisfaction as early as age nine, and have other harmful effects on psychological well-being like anxiety (Pacilli et al. 2016). Moreover, the sexualization of children in advertising, television programs, music videos, and games instructs girls as young as primary school age in erotic body movements, dancing, and clothing. Trekels et al. (2018) found that women in fashion magazines, social media, movies, and music videos are positively related to and showed some unique and significant contributions in self-sexualizing behaviors in children. Psychologists noted that this results in children believing they need to escalate their level of sexual behavior to attract attention, and the normalization of the sexualization of children prepares them to be groomed by pedophiles and human traffickers (Rush and La Nauze 2006). One particularly egregious example of this is Teen Vogue which printed an article in April of 2019 extoling the virtues of sex work and advocating for its legalization to their teen and pre-teen audience (Mofokeng 2019).

Poverty Perhaps the most dominant of the societal factors is poverty (Walters and Davis 2011). When poverty is combined with limited or nonexistent support systems, the

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child’s vulnerability factors increase substantially. In cities and other urban areas, traffickers actively recruit these vulnerable children. The connection of poverty to human trafficking and sex tourism is perhaps one of the primary factors. Sadly, some families sell their children into the sex trade. Although street and orphaned children are particularly vulnerable to trafficking into the sex industry, a large percentage of children who have been trafficked continue living with their families and engage in commercial sexual activity in order to contribute to household income (Walters and Davis 2011). In some rural communities, parents will willingly allow people to take their children believing that their child will have a better opportunity for education, nutrition, and employment in a larger nearby city. Sometimes the parents and children both sense that they might not receive the promised benefits, but the hope of the opportunity outweighs their doubts about the veracity of the offer. It is not uncommon for that child to be forced into sex tourism believing that it is his or her responsibility to help the family through these means. During an interview, a Cambodian girl indicated that soon she would be able to stop working in the sex industry and attend school because she would be replaced by her younger sister, allowing her to get an education and still provide for her impoverished family (Lim 2017).

Effects of CSEC The effects of CSEC are often multifarious, detrimental, and long term. The victimized often present with a myriad of health, mental health, legal, educational, familial, and spiritual needs (Baker and Grover 2013). Goldberg et al. (2016) examined the medical presentation of the child trafficking patients and found that trafficking victims had frequent contact with medical and healthcare professionals. They reported a frequency of mental health problems including suicide attempts. The youth also reported psychosomatic complaints such as abdominal pain and gynecological concerns including vaginal pain, itching, or bleeding. Shame, guilt, and humiliation are common feelings expressed by victims of child pornography. They are hesitant to discuss the images with law enforcement or counselors, and some even refuse to recognize that the images exist. This is especially true of male victims, who are often concerned that they will be considered homosexual because of a sex abuse situation. Victims may fear their images will be shared for the rest of their lives. However, some victims find peace in having proof that the pain they have suffered is real and especially that there is clear evidence available to use to convict the offenders (Gewirtz-Meydan et al. 2018). Children who are victims of child sex tourism constantly live in fear of sadistic acts by clients, violence from pimps, and suffer from depression and feelings of hopelessness. Moreover they experience three times higher rates of suicide and face a host of medical and mental health problems as a result of their abuse (Walters and Davis 2011; Estes 2014).

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Offender Characteristics Child Sex Trafficking Similar to the literature connected to child sex trafficking victims, the literature focusing on the offenders is also scant. The predominance of the limited literature reports that traffickers can be family members, intimate partners, acquaintances, or total strangers to the victims. They come from diverse social and economic backgrounds (Raphael and Myers-Powell 2010). Similar to victims of child trafficking, offenders often have a history of physical abuse, sexual abuse, running away from home, and involvement with the foster care system. Raphael and Myers-Powell (2010) found that many of the traffickers in their study reported that pimping allowed them to regain a sense of power since they had not had any power as children.

Child Pornography A multitude of studies have attempted to determine a description for a typical child pornography offender. While some have successfully identified commonalities among their subject group, those results invariably conflict with another study of another group. This leads us to believe that child pornography offenders come from all walks of life and all demographic categories (Mccarthy 2010). Numerous studies have been conducted to identify types of child pornography offenders. Years of consolidated research have found commonalities in groupings that can be narrowed down to four definable types: • Periodically prurient offenders – accessing child pornography is a small part of a greater interest in pornography as a whole. These offenders have no specific interests in children beyond general curiosity and may seek out a wide variety of types of pornography, including extreme and sensational images. • Fantasy-only offenders – images of child pornography are sought to drive a sexual interest in children. These offenders are not known to have any history of sexual contact with a child. • Direct victimization offenders – utilize child pornography for a variety of purposes, including grooming and for their own gratification. Child pornography is a part of a greater group of offenses, including contact offenses against children. These offenders often use technology to find and groom victims for later contact offense (Elliott and Beech 2009). • Commercial exploitation offenders – child pornography is a tool for financial gain for these offenders. They may be involved in production or distribution of child pornography. These offenders may or may not have a sexual interest in child pornography themselves but are primarily financially motivated (Lanning 2010). These typologies can be helpful in identifying the motivations behind child pornography offenders, what their risk may be to potential victims, and whether there is reasonable concern that multiple victims exist for an offender (Lanning 2010).

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Child Sex Tourism “The evidence gathered for the Global Study finds that traveling child sex offenders do not fall into neat categories. Pedophiles and preferential offenders remain grave risks – looking for and exploiting every possible means to gain access to children – and this is emphasized across the research. Preferential perpetrators are individuals who travel with the deliberate purpose of having sex with children” (Hawke and Raphael 2016). Some offenders intentionally plan their travel to gain sexual access to children, while others may unintentionally engage in child sex tourism while intending to solicit an adult. “While some offenders are pedophiles who preferentially seek out children for sexual relationships, others are situational abusers. These individuals do not consistently seek out children as sexual partners but do occasionally engage in sexual acts with children when the opportunity presents itself” (Extraterritorial sexual exploitation of children 2018). Those who traffic children into sex tourism vary greatly in terms of their organization and sophistication; however they all use manipulation and/or force to exploit the vulnerabilities of children. “Any point of vulnerability can be used by a skillful manipulator to make another person do things and stay in situations that they would otherwise never do or stay in” (Lim 2017). The role of the trafficker varies. One egregious example is law enforcement or judges receiving compensation for their role in the miscarriage of justice. Traffickers may be an individual or a group of organized criminals. Another type of trafficker is those who facilitate the selling of children to tourists for sex. These are recognized to be key middlemen in sex tourism. They offer a number of different services to tourists both licit and illicit. They will identify clients and girls/boys alike and negotiate rates and a venue. They, like the female sex workers, are looking for tourists, men or women, to form long-term and commercially fruitful relationships. A few operate as pimps with a “stable” of several girls for whom they obtain clients. This is more common among Muslim and local girls who face greater risks if they are seen soliciting in public. From focus group discussions, these middlemen are usually close male relatives, “helping their sisters get business.” Commissions are charged at up to 50% of the negotiated rate (Jones 2006). Facilitators in Japan are organized crime syndicates, taxi drivers, police officers, and transporters. In Jamaica, a culture of tolerance for the commercial sex industry has been created and fostered by extreme poverty and “make do” attitudes for survival in the wake of the once-booming tourism industry. Facilitators in Jamaica are primarily organized gang members, police officers, taxi drivers, and hotel staff. In the Netherlands, a centuriesold culture of tolerance has long been in place resulting in the legalization of prostitution and the promotion of its red-light district as a major tourist attraction. The Netherlands facilitators are often not only organized gang members and taxi drivers but also “loverboys” or fake boyfriends, landlords, and tour operators. The culture of tolerance in the United States is perpetuated by the glamorization of the pimp/prostitute lifestyle while condoning lapses of morality when on vacation through slogans like “What happens in Vegas stays in Vegas,” for example. Facilitators in the United States are typically young pimps, taxi drivers, and hotel/club staff (Estes 2014).

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Cultural Considerations for Prevention and Intervention of CSEC Fong and Berger Cardoso (2010) specifically focused on the issue of CSEC from the viewpoint of the child welfare system. They called for child welfare administrators to consider more specialized services for CSEC victims. Solutions to end CSEC must be comprehensive and collaborative to be effective internationally. However, most efforts have not begun with international or even regional support. Many of the most effective organizations and agencies combating this issue today began as a small group of people driven by a focused mission, typically focused on either prevention, victim recovery, or legislative and legal efforts. Successful efforts to combat CSEC must address prevention, victim recovery and restoration, and the investigations and prosecution of the offenders. The push factors creating the vulnerabilities for the potential victims are mitigated on a macro level through broad-based cultural changes and on a micro level by strengthening the family. Each of the causal factors creating the problem of CSEC must be corrected in order to eliminate the issue. Trying to do anything else, or less, will result in ineffective responses. Non-governmental organizations, churches, and community groups play an essential role in supporting the family and providing an opposing morality to the sexualization of children in the media and culture at large. Small local nonprofit organizations when well trained and implementing best practices are the most efficient way to help survivors heal and become reestablished in a community. Many small nonprofits have sought funding through government grants enabling them to expand their programing and strengthen their administrative processes. The effectiveness of these agencies is their knowledge of and access to local resources and their inherent ability to effect change quickly. Some non-governmental organizations focus on macro issues rather than providing direct services to survivors. These organizations are an essential partner to the local organizations because they provide the expertise and access to policy makers that are needed to create sustainable systemic change. Some of the most effective organizations include Thorn, which uses technology to help law enforcement and develop awareness campaigns (“Our Work to Defend. . .” n.d.); the International Justice Mission (IJM), a Washington D.C.-based NGO that, according to its website, rescues slaves, works with police to throw slave owners in jail, and puts the slave trade out of business (“Our Work: International. . .” n.d.); and Shared Hope International, which uses a three-pronged approach to prevention, restoration, and bringing justice through legislative change. Other organizations have been established by governmental mandate or assistance such as the Polaris Project which leverages data and technology to pursue traffickers wherever they operate (“About Us” 2020) and the National Center for Missing and Exploited Children which assists victims, families, and law enforcement (“Child. . .” n.d.). Smaller local nonprofit organizations, community groups, and churches provide the victims and vulnerable people access to services and support. This is essential for the healing and restoration of the survivor and to prevent other potential

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victimizations. The larger national and international non-governmental organizations often partner with these local organizations for direct services, but they also provide the policy and legislative support to the communities required for sustainable solutions. Finally, international coordination is necessary because not only does this crime not respect borders within a country, but CSEC by definition knows no international borders as well. Some international partnerships have developed to combat the exploitation of children. One of the most effective is ECPAT, developed in 1990 by an international committee of people united to End Child Prostitution in Asian Tourism (History, n.d.). As discussed previously, the United Nations has created instruments of international law to address this problem. “In support of enforcing these instruments, the UNODC established the United Nations Global Initiative to Fight Human Trafficking (UN.GIFT) in 2007” (King 2018). “UN.GIFT works with all stakeholders - governments, business, academia, civil society and the media - to support each other’s work, create new partnerships and develop effective tools to fight human trafficking” (UN.GIFT n.d.). Global initiatives to end CSEC should include international agreements that provide the foundation upon which industry policy statements, regional political standards and commitments, as well as legislative measures can be built upon. National plans of action must involve coordinating stakeholder involvement to build capacity, provide training, and conduct awareness campaigns. Consideration should be given to ensure that a community and its businesses have a clean value chain which engages in responsible sourcing. Finally, there must be clear reporting systems and communication systems between agencies and organizations for the collection and analysis of data and for the execution of efficient programs and operations (Hawke and Raphael 2016). Many of the initiatives for global success are applicable for community or regional efforts as well. Additionally, because CSEC is often facilitated either knowingly or inadvertently by local vendors, awareness training for taxi drivers, guides, and market vendors should be implemented along with developing and providing training and awareness programs directed at law enforcement and other service providers (fire, EMS, social services, school systems, etc.,) on recognition of and response to trafficking. Training for local law enforcement, prosecutors, and judges on model programs for interdiction, investigations, prosecution, and prevention is also essential. There is a need to develop programs targeting juveniles at high risk for victimization and exploitation, with the goal being to intervene, redirect, and support runaway, throwaway, and exploited children who are at risk of trafficking or who are being exploited. There is also a need for the development of public service programs to reach out to victims of trafficking, educating the victim on their rights and protections, with the aim of increasing the number of self-referrals and rescues. Local communities will need to create collaborative programs with their bordering communities to combat trafficking, sex tourism, and exploitation. Finally, local efforts should create teams of researchers, journalists, social service groups, advocacy groups, and law enforcement to develop “on-the-ground” and “real-time” information relating to strategies employed by traffickers, numbers of victims

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being trafficked, and to develop a comprehensive understanding of sex trafficking as it is interrelated to labor trafficking, drug trafficking, and other organized criminal enterprises (Walters and Davis 2011). All policies, programs, and treatments must be trauma-informed and victim-centered (TIVC). A TIVC approach takes under consideration the effects of complex trauma on the victim as it relates to their ability to provide testimony, exhibit healthy relationships, maintain stable housing, resolve conflict, make mundane decisions, and implement positive coping skills, and a plethora of other capacities. Thus, law enforcement, the courts, treatment programs, counselors and therapists, medical staff, teachers, and employers all need to make accommodations to their processes and policies to ensure the best possible engagement opportunity within each of those industries and disciplines. In doing so not only will the trauma responses of the survivor be mitigated; the objectives of the professional will be met, and the survivor will be positioned for success and healing. A trauma-informed victim-focused approach will result in better investigations because law enforcement will be better prepared to work with a victim of complex trauma. It will result in more convictions because prosecutors and judges will make accommodations to victims while they testify, resulting in better evidence. Medical professionals will be able to accurately triage patients resulting in more effective medical treatment. Counselors and therapists will be able to help their client navigate through their recovery more effectively. Each professional industry will be able to provide their services to the survivor in a manner that allows the survivor to heal and recover in the most appropriate way for that individual.

Key Points • The commercial sexual exploitation of children (CSEC) is a global issue encompassing a wide range of activities including forced prostitution, pornography, stripping, dancing, sex tourism, etc. • Legislation addressing CSEC has been drafted domestically and between nationstates through various Acts and Protocols. • Traffickers exploit the vulnerabilities of victims created by various factors including family conflict, societal pressures promoting the objectification of girls, poverty, and the lack of awareness and training in the industries and professions that engage with victims of human trafficking. • CSEC has many effects on victims that are comprehensively impacting them psychologically, physically, mentally, emotionally, educationally, legally, spiritually, and relationally. • Traffickers and consumers come from every socioeconomic background resulting in no actionable offender profile. • Prevention and intervention strategies must include child welfare, non-governmental organizations, churches, law enforcement, community organizations, educators, medical professionals, courts, and mental health. • All aspects of victim engagement including policies and processes must be trauma-informed and victim-focused.

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Summary and Conclusions Successfully understanding and addressing the issues surrounding the commercial sexual exploitation of children is essential to deriving effective solutions. The tendency to sensationalize and politicize the issue of human trafficking only results in greater vulnerabilities for victims and the institutionalization of impotent programs and policies. CSEC knows no cultural, political, economic, or geographic boundaries; therefore the solutions must be based on applied research that includes the perspective and voice of survivors of human trafficking. Solutions to human trafficking in general and to CSEC in particular must be comprehensive, trauma-informed, and victim-focused. Preventative and restorative efforts should focus on mitigating vulnerabilities and empowering strengths. Programs, policies, and legislation should be crafted with the understanding of how they are impacted by the trauma responses of the victims. Human trafficking and CSEC can be eliminated when there is a combination of corporate will and deep collaboration in a community and society.

Cross-References ▶ Adverse Childhood Experiences: Past, Present, and Future ▶ Examining Interpersonal Violence from a Trauma-Informed and Human Rights Perspective ▶ Health and Mental Health Consequences from Sexual Trauma Victimizations ▶ Human Trafficking and Intimate Partner Violence ▶ Mimickers of Child Sexual Abuse ▶ Sex and Labor Trafficking: Trauma-Informed Themes Toward a Social Justice Approach ▶ Sexual Abuse of Children ▶ Treatment Considerations for Youth Exposed to Interpersonal Violence

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Outline of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I. The Crisis of Institutional Child Abuse in Residential Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A. The Institution and Child Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. Legal Efforts Against Maltreatment in the USA: Mandatory Reporting . . . . . . . . . . . . . . . . II. Non-correctional Institutional Environments for Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. Maltreatment Risks and Realities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III. Correctional Environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. Sexual Victimization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C. Physical Victimization, Suicide, and Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV. Institutional Environments and Children with Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. Sexual Victimization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C. Other Maltreatment Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 949 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 949

Abstract

This chapter broadly examines the risks of child maltreatment as it manifests itself in institutional environments in the USA. For the sake of organization only, the chapter is divided into an examination of three types of institutional settings: (a) non-correctional environments generally, (b) correctional environments generally, and (c) institutional settings for children with disabilities. It should be noted, however, that in many sources of literature and study on the subject, these three designations sometimes overlap and are not always discussed separately or in the manner depicted here. In addition to providing examples of particular risks within different types of institutional settings, this chapter identifies an important but heretofore mostly illunderstood risk of institutional maltreatment: the infiltration of institutions by predators and other harmful people. This infiltration is due in part to flawed institutional responses to suspected cases of child maltreatment throughout history. A distrust of civil authority and/or an instinct for self-preservation has led time and time again to the cover up or minimization of child maltreatment in institutions. These substandard responses serve to attract even more abusive people to these institutional environments, knowing that their misdeeds are not likely to be addressed.

Keywords

Child abuse · Neglect · Maltreatment · Mortality · Institution · Mandatory reporting · Corrections · Confinement · Disability · Intellectual disability · Deafness

Introduction Institutional care for children in the USA is a child welfare function and practiced mostly by states and some localities. However, some religious and private institutions exist, particularly for children with disabilities. Internationally, institutional childcare is often related to a religious institution, although governments perform the function as well. Residential childcare in the USA can be provided under the auspices of a mental health agency, as a part of the juvenile justice function, under a state or municipality’s developmental disabilities responsibilities, or as an education function. Residential placement (generally excluding cases involving a profound disability) usually happens after a lengthy juvenile or family court process, although the placement can be voluntary. The process may be initiated due to the child’s

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delinquent or criminal behavior or due to circumstances beyond the child’s control (family crisis or maltreatment of the child) (McCoy and Keen 2014). Laws and policies throughout the USA direct that residential placement is only appropriate if measures less restrictive (and less disruptive to the family environment) are exhausted or deemed inadequate (U.S.C. §675.5). Thankfully, while rates of outof-home placement are still high, they have decreased in recent years; as an example, around 532,000 children, most of them older than 12, were in residential placement (including correctional environments) in 2002 (AFCARS Report #12). That number decreased to 487,283 in 2018 (AFCARS Report #26). The risks to children in institutional environments for maltreatment (abuse and neglect) are myriad and mostly intuitive. The very nature of an institutional setting rather than a traditional family setting suggests a less nurturing and more standardized, impersonal approach to childcare. Strained budgets and eternally inadequate resources plague most facilities. Children from compromised family backgrounds suffer from physical, mental, and emotional ailments, many of them undetected, undiagnosed, and untreated until the child reaches the institutional environment. Some of these issues make the child’s behavior difficult to understand and manage. Similarly, children who are institutionalized because of delinquent or criminal acts often appear less sympathetic than non-offending children and are viewed by society simply as menaces rather than persons in need of care and focus. Other children, sometimes from apparently healthy and functional family environments, nevertheless require institutionalization simply because of a disability or condition that cannot be addressed within the traditional family setting. Whatever the reason for the placement, a common factor to virtually all children in an institutional setting is relative helplessness. Children do not have the power or the wherewithal that adults have to navigate their environment and specifically to navigate away from it when the environment becomes abusive. Children lack not only the financial and logistical means but often the legal right to leave any environment, whether institutional or familial. Institutional environments can be “secure,” amounting to confinement, or may be located in remote areas far from anything familiar. In either case, the child is essentially trapped within the environment, whether there are locks on the doors or not. Sadly, predatory and otherwise abusive individuals understand how helpless children are in institutional settings, particularly residential ones. Some, finding themselves in an environment where their charges are relatively helpless, will abuse or neglect them for a variety of reasons, usually without fear of detection let alone sanction. Predatory individuals often seek to infiltrate institutional settings simply because these institutions contain a steady stream of relatively helpless victims (Salter 2003). Even more tragic is when the institution itself, rather than quickly and comprehensively addressing the detected maltreatment, minimizes it or seeks to cover it up in order to protect its reputation. As this chapter discusses, such behavior by institutional leaders not only prevents a weeding out of abusive staff but actually attracts more predators due to the emerging perception that the institutional environment will protect them.

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Outline of Contents I. The Crisis of Institutional Child Abuse in Residential Settings A. The Institution and Child Abuse B. Legal Efforts Against Maltreatment in the USA: Mandatory Reporting II. Non-correctional Institutional Environments for Youth A. Overview B. Maltreatment Risks and Realities III. Correctional Environments A. Overview B. Sexual Victimization C. Physical Abuse, Neglect, and Suicide IV. Institutional Environments for Children with Disabilities A. Overview B. Sexual Victimization C. Other Maltreatment Risks

I. The Crisis of Institutional Child Abuse in Residential Settings A. The Institution and Child Abuse Institutions have for centuries existed to provide residential, instructional, rehabilitative, and correctional care to children. This has often occurred when traditional family caregivers have been absent, unwilling, or unable to provide such care themselves. However, there are situations even today where parents who are willing to care for children, often with special needs or challenges, are pressured or even forced to put their children in institutional care. Although this was far more widely practiced in previous generations, children are still remanded to institutional care, particularly in cases where the child has a severe disability or other physical, mental, or emotional challenge. Sadly, history groans with the tragedies and evils associated with the institutional care of children, perhaps even more so in the popular mind than with the abuse and neglect perpetrated by individual families through time. Institutional care is – by definition – less nurturing, personal, loving, and individually tailored than care within the traditional family setting. Still, there are millions of dedicated men and women in thousands of benevolent institutions who strive every day to make the lives of children better with the resources available. Often these efforts bear fruit, and children within institutional settings adjust, develop, heal, and thrive. Far too often, however, negligence, incompetence, predatory behavior, or some combination of these conspire to make the lives of children in institutions far more than challenging or difficult and instead make them hellish (Goodstein and Callender 2010). Of course, the limitations and risks of institutional care of children have been understood for a very long time. But what has only recently been understood is a particular characteristic of too many institutions which make them even more

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dangerous as places to house children. This distinct and dangerous aspect of institutional culture goes far beyond the usual impediments to decent, effective care, such as a chronic lack of resources and support or even simple mismanagement and human failure. Rather, it is the instinct for self-protection within institutions that often makes them such continuous sources of misery. The instinct by leaders to protect the institution over the well-being of the children they serve leads to covering up or minimizing maltreatment. It also makes the institution attractive to abusive or predatory people who will seek to infiltrate it. Simply put, when predators perceive that an institution’s reaction to suspected maltreatment is lackluster, they will naturally gravitate toward it. In becoming willfully blind to abuse within their environment, institutional leaders become not only complacent in the continued maltreatment, but they actually invite more of it, making their institution more dangerous and damaging over time. This becomes a vicious cycle in which the children the institution is meant to serve become its most tragic victims. This is not to suggest there is a simple cause of the plague of child maltreatment in institutional settings. Many causes continue to impede efforts to provide children with the best possible care and treatment in modern institutional settings. But the failure of institutions to prevent and react appropriately to abuse and neglect because of (i) a distrust of civil authorities and/or (ii) an instinct for self-protection is one that has traditionally remained shadowed. Only with developments of the last 20– 30 years, such as the Roman Catholic Church sexual abuse crisis (and more recent revelations of institutional child sexual abuse within evangelical churches, Jewish and Muslim institutions, and others) (Berkovitz 2017), has the issue attracted further study. One relevant fact to consider is that, around the world, many institutions that care for children are related to religious organizations. Many such organizations over time have distrusted civil or secular authority, often understandably so given religious persecution. Other recent discoveries regarding child abuse within institutions include revelations about youth activities like athletics, scouting, music, and theater (Gunderson 2014). These organizations, some of them with a global presence and generating great wealth, may not have the innate distrust of civil authority because of religious persecution but are still interested in the protection of their “brand” and reputation. What we now know is that no institutional environment, from Little League to international service organizations, is safe from predatory elements seeking to infiltrate it in search of a steady stream of trusting and relatively helpless victims (Salter 2003). Every institution must safeguard itself as best as possible, understanding that no technology, data source, or set of interview questions will successfully prevent infiltration. Rather, the far more effective strategy is to make the institution less attractive to predatory people, largely by following simple guidelines (like requiring at least two adults to be present with one or more children in every situation) and by publicizing both their guidelines and their commitment to work with civil authorities and the outside world to ensure child safety (Saul and Audage 2007).

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Nowhere is this commitment more important than where the residential care of children is concerned. The consequences of maltreatment in childcare facilities have been studied extensively and have found to be related to a variety of negative outcomes. Health risks like suicide, hypertension, obesity, substance abuse, and psychiatric disorders have been linked to maltreatment (Felitti et al. 1998) as has the greater risk of involvement with the criminal justice system, both in adolescence and adulthood. Child sexual abuse is linked to further sexual abuse later in life and generally unhealthy approaches to sex and sexuality across the life span (Finkelhor et al. 2007). Chronic neglect, as can happen in an institutional setting, can lead to developmental delays, cognitive and academic deficits, serious physical consequences (lack of dental care, proper vaccinations, and nutrition), and early death (Gaudin 1999).

B. Legal Efforts Against Maltreatment in the USA: Mandatory Reporting Mandatory reporting laws have sought to make a difference in terms of how child abuse is reported and followed up on, and these laws apply to children in institutional settings as well. In all US jurisdictions, a mandatory (or mandated) reporter is a professional who is obligated by law to report known or suspected incidents of child abuse and/or neglect. Originally only applicable to physicians, these laws in most US jurisdictions have been expanded to include almost all professionals who regularly interact with children (Matthews 2015). By definition, then, mandatory reporting laws include professionals working within institutional settings where children are served. Importantly, they have been expanded (as of 2016) to clergy in 28 US states and the US territory of Guam (Child Welfare Information Gateway 2019). This expansion of mandatory reporting to clergy is crucial if child abuse occurring within religious institutions is to be curbed. Religious institutions are among the largest worldwide where interaction with and care for children are concerned. Requiring not only lay professionals but clergy themselves to report suspected child abuse is designed to create personal accountability within the religion’s core authority. In some states, however, mandatory reporting can conflict with the traditional “clergy penitent” legal privilege which protects the confidentiality of certain communications between a confessing person and clergy (Bartholomew 2017). However, a few US states (Guam, New Hampshire, and West Virginia are examples) deny the privilege in any case where child abuse and neglect are concerned. Importantly, mandated reporters must at least orally report their concerns directly to their jurisdiction’s child protective service agency (and not to a supervisor or other official within the institution). Further, the individual mandated reporter’s concerns do not alleviate the institution’s separate responsibility to report the suspected maltreatment. At their most effective, these laws purposely place a legal responsibility (with criminal consequences for noncompliance) on the part of the professional to report directly to a civil agency and not “up the chain” within the institutional setting.

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Unfortunately, mandated reporting laws are notoriously difficult to enforce. They are considered to be lower level offenses (misdemeanors) and rarely prosecuted. Worse, in confidential surveys, many mandated reporters will admit not following the law even when strong suspicions of child abuse and neglect have been observed (Vieth 2006). Others seem to struggle with feeling confident enough about making a mandated report, and many do not feel properly trained to recognize child abuse and neglect. This is a real concern, as some US jurisdictions still do not require that all mandated reporters have adequate training to recognize signs of abuse and neglect (Alvarez et al. 2004).

II. Non-correctional Institutional Environments for Youth A. Overview Non-correctional institutional environments for youth include many types of settings, such as group homes and residential treatment centers, emergency care and shelter care facilities, licensed foster, preadoptive or kinship care homes for children, runaway shelters, licensed childcare homes and facilities, acute psychiatric care facilities, and facilities for children with disabilities (discussed in more detail below). These environments can be public or private, and oversight of them differs from state to state in the USA as well as within states themselves. In general, children and adolescents enter these environments through no fault of their own. Their placement is usually court-driven because of abuse, neglect, or abandonment, or for any other reason it is determined that the child cannot remain at home safely. With regard to US federal reporting and monitoring (usually done by the Department of Health and Human Services, Administration for Children and Families), the term “foster care” includes most of the non-correctional environments described above. Recent data compiled by the Census Bureau puts the number of US children in foster care at around 400,000, which is down from numbers eclipsing 500,000 from 1998 through 2002. Of these children, almost half are in nonfamily foster placement, around 28% are in family foster placement, about 7% are in a group home setting, and around 9% are in a supervised, institutional setting (AFCARS Report 12). An important related figure is that, while the total number of children in foster care at any given time might be around 500,000, the number of children who will go through foster care over the course of a year has averaged as high as 700,000 according to recent data (O’Hare 2008). The total number of children in institutional care internationally is difficult to determine, but estimates suggest that the number is as high as eight million (Barriga et al. 2017). All of these institutional environments become necessary when a child is removed from the family setting and placed in out-of-home care, sometimes voluntarily and sometimes as a result of a legal process. Current US law and policy mandate that the least restrictive residential alternative be used for the child’s placement and that relatives of the child be given priority in placement decisions (U.S.C. §675.5). Sometimes, however, foster care for a child will be with a non-

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related family, certified by the state to care for the child. Other times, and because of more recent attempts to reform the process, foster care can involve the entire at-risk family going to live together in a larger, supervised environment. Lengthy court involvement usually precedes out-of-home placement, but some children are removed from their birth homes in what are called emergency removal situations. These removals are temporary, and in all US states, they require follow-up with the local juvenile or family court, usually within 72 hours. Emergency removal is most often carried out by child protective services agencies, sometimes in conjunction with law enforcement. Emergency placement may be in a family setting (like foster care) or may be in a shelter-type environment (sometimes referred to as “ShelterCare”) depending on the jurisdiction. Therapeutic foster care or residential placement occurs where there is a particular need to focus on a child’s disability, illness, emotional or mental health issue, or behavioral concern. Although state law and policies across the USA favor family placement (or at least placement in a family environment), therapeutic environments may be necessary when the child’s challenges and needs are beyond the ability of the typical home environment to address. As of this writing, about 1/5 of all children in out-of-home care are in residential facilities rather than home-environment foster care, although the reasons for the placement differ and are not all related to therapeutic needs (this 1/5 figure also includes children in correctional settings, discussed below) (Bullard and Johnson 2005). A 1992 study conducted in New York State found that children in residential settings are often at higher risk for maltreatment when they come to the institution with emotional or mental health issues and when they are perceived as acting out and/or engaging in provocative behavior as a result of past maltreatment (Blatt 1992). The study notes that children are sometimes placed in institutional settings because they are uncontrollable in other settings. Regardless of the genesis of such behavior, the difficulty in reacting to and controlling it in a non-abusive, nonneglectful manner is obvious. Staffing issues are also cited as possible reasons for increased maltreatment in institutional settings, with low pay, long hours, high stress, and inadequate resources all being factors. It has also been observed that most incidents of abuse occur in the late evening or early morning, times when staffing levels may be lower than normal (Blatt 1992).

B. Maltreatment Risks and Realities Maltreatment risks to children in institutional settings stem from many factors, including the unavoidably less personal and less individualized nature of the care provided, a lack of bonding in many cases between the child and the caregivers, and the sometimes transient and shifting nature of nonhome care placement. All of these challenges can be made worse because so many children who enter the foster care system are suffering from pre-existing conditions related to mental and physical illness (often undiagnosed), poverty, and maltreatment in their birth environment. Dental problems are also a common issue for children entering nonhome care, as

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things like poverty or neglect often leave children with painful conditions such as cavities or misalignment of teeth. The resulting chronic pain can affect mood, behavior, sleep, and a host of other factors (Valencia-Rojas et al. 2008). All of these pre-existing conditions can lead to behavioral problems and issues with communication or personal interaction. Or, they may simply require more focused attention than institutional caregivers can provide. The powerlessness of children in any institutional setting must also be considered. As in any environment where abusive, neglectful people are found, the relatively powerless among them are likely to be targets. In a childcare institution, the child herself is at a terrible disadvantage when facing physical abuse, sexual abuse, neglect, or any combination of these. Indeed, many children are unable to describe maltreatment because of their disabilities or perceive it to be no different from their day-to-day reality. If they do feel abused, they may lack the skills to communicate it. Even if they are able to make a report, they may find themselves isolated, ignored, or retaliated against by staff and other children. A child in an institutional environment finds less individualized care and less of a focus on him or her as an individual. The child also faces a demand for harmony and structure for the sake of the larger group. These characteristics can have some positive effects, such as children learning to coexist with others in aspects of daily life. However, they can also create a situation where the child is a “cog in a wheel” with less recourse when ignored, abused, or deprived by anyone around them, including other children. Of special concern are forms of maltreatment that are particularly subtle, such as emotional neglect. A child’s physical and basic educational needs may be met in that proper nutrition, hygiene, medical care, and schooling are provided. But the child is left without emotional support and guidance during times of stress or sadness or through milestones like puberty. It should be noted that, while maltreatment of children in institutions is very real (and almost certainly more prevalent outside of the USA), institutional providers in the USA account for a very small percentage of reported perpetrators of abuse and neglect. US government data from 2016 showed that about 0.2% of perpetrators of child maltreatment were in a foster parent role. The same data show that about 0.3% of perpetrators were group home or residential facility staff members. For context, biological parents account for almost 80% of all child maltreatment cases generally (Euser et al. 2014). Further, it is evident that thousands of institutions and millions of men and women strive to provide compassionate and comprehensive care for children outside of the birth environment, and success stories of children in these environments abound. However, failures are frequent. Perhaps even more disheartening, though, is how the fates of institutionalized children may appear far short of “failure” by some objective measure but still be reflective of a life not allowed to flourish to its full potential. For instance, a child may have a tremendous gift for music, writing, science, or another field of endeavor. Without an attentive and encouraging nurturer or mentor, however, the gift may go untapped and undiscovered. Although the child may receive objectively adequate health care and education during her time in the institution, her true potential will not be realized.

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The prevalence of child maltreatment in group settings (residential homes or foster family homes) has been documented to be higher than in the general population (i.e., children in traditional home settings); specifically, a higher rate of physical and sexual abuse has been detected in group settings than in the general population (U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau). Sexual abuse has been found to be more prevalent in residential homes than in foster care, although the rate of sexual abuse does not appear to differ between a foster care environment and the general population. For adolescents in particular, physical abuse in residential homes has been shown to be twice as prevalent as in foster homes and three times as common as in the general population. These data would suggest that residential facilities in particular can be dangerous places for older youth especially. There are characteristics of families who take in foster children in the USA which could provide a basis for concern. US Census data shows that foster families (as opposed to traditionally composed families) are reported to have more children in the home environment and a higher ratio of children to adults (Rus et al. 2017). Foster families are often economically less advantaged than families without foster children. Additionally, for some foster parents, a job outside the home is not possible due to the extent of the care required for the foster children. This can strain resources and create stress, leading to neglect or even abuse. Globally, the plight of institutionalized children can be truly nightmarish. Research conducted since the fall of the communist system in 1989 from Romania, for instance, has documented the actual stunting of growth by children who spent extended periods of time in institutional placement (Rus et al. 2017). The privations and maltreatment found in the old Romanian system of childcare, now completely restructured, are extreme and not emblematic of institutionalized childcare everywhere. But similar evidence of substandard care has been documented in Greece, Ukraine, India, Indonesia, and Central American countries (Barriga et al. 2017). The USA is generally recognized as providing better institutional childcare than most studied nations, although methods of measurement and determinations of adequacy differ between cultures and geographic locations. As mentioned above, the subtler forms of child maltreatment, such as emotional and educational neglect, verbal abuse, or unnecessary isolation, can have far-reaching consequences even if they are not apparent during the term of care. The Romanian experience during the late years of its communist regime, for example, is a particularly terrible lesson: in Romania from the late 1960s onward, fields like psychology and social work were severely curtailed, the professions deemed subversive or otherwise incompatible with communist ideology. So, in Romania under the regime of Nicolae Ceausescu, even when the basic physical needs of children were met in Romanian institutions and education was provided, their emotional development and emotional well-being were largely ignored. This led to terrible long-term consequences for institutionalized children, and they stand as a reminder that subtler, less visible forms of child maltreatment in institutions need to be guarded against as well.

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III. Correctional Environments A. Overview According to US Department of Justice, Office of Juvenile Justice and Delinquency Prevention, approximately 43,580 youth were held in residential placement facilities in the USA in October of 2017. This number reflects a “1-day count” and includes both local- and state-level facilities. This 1-day count reflects a sharp decline over a 20-year period, down from well over 100,000 on a given day in 1997. Most of these youth were held in juvenile facilities (state, local, and private facilities), but in general around 10% of youth in custody (for instance, approximately 4,200 youth on a typical day in 2014) were held in adult jails. And, an older 1-day count from 2013, using data from US Department of Justice (USDOJ) sources, stated that around 4,400 youth were in adult jails and almost 1,200 in adult prisons. In terms of gender, approximately 15% of the total number of juveniles in custody in the USA were females in 2017 (USDOJ, OJJDP Statistical Briefing Book). Custody in the juvenile justice system in the USA varies widely in form, structure, and level of security. The above 1-day count encompasses youth from most of these differing types, including the following: (a) temporary facilities, usually local or regional detention facilities where youth are held either for relatively minor offenses after juvenile court adjudication or in anticipation of adjudication; (b) state-level facilities where youth are “committed” either for open-ended or determinate sentences for various offenses, usually more serious in nature or reflecting failed attempts at lesser forms of restriction; and (c) adult correctional facilities (jails and prisons). The dangers to youth in any correctional setting involve many different sources of potential risk and harm. It is axiomatic that youth who are committed to correctional facilities or otherwise detained for various offenses are often from compromised family situations. Many incarcerated youth have mental health issues or suffer from emotional disturbances, some of which remain undiagnosed until the youth becomes involved with the justice system. Notably, court involvement often occurs not because of an act that would be a crime for an adult but because of a “status” charge. Status charges include things like being a runaway or being incorrigible (the “status” of existing beyond parental control in an unlawful manner), underage alcohol possession, truancy, and curfew violations. Status offenses are very common and often result in at least temporary confinement for the youth involved (Census of Juveniles in Residential Placement data from 2011 showed 2,000 status offenders were held in residential placement) (National Council of Juvenile and Family Court Judges 2011). Because status offenses are almost always related to systemic family difficulties not of the child’s making, many juvenile and family court practitioners are pushing to end confinement and correctional environments for status offenders. Still, many status offenders are subjected to correctional environments and lockup at least temporarily, and status offenses are often soon followed by delinquent or criminal acts in any event due to the underlying causes. Many confined youth are themselves crime victims or victims of abuse and neglect and/or come from families with regular court involvement. It is also true

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that children, particularly adolescents, who have been found guilty of criminal offenses are less sympathetic than other youth; the public may not take as deep an interest in their welfare or treatment because of their perceived transgressions and behavior. This, in turn, can lead to strained resources for incarcerated youth in budgeting decisions the same way it does with incarcerated adults.

B. Sexual Victimization Sexual victimization is regularly reported in juvenile correctional settings. According to the 2012 National Survey of Youth in Custody, nearly one in ten (9.5%) adjudicated youth reported being sexually victimized in juvenile facilities (Mandel 2015). Sexual misconduct by staff was the most prevalent form of victimization, reported more than twice as frequently as youth-on-youth victimization. Force was reportedly used in a little less than half of the 2012 incidents reported. Demographically, males are likely to experience sexual victimization more than females. Black and nonheterosexual youth are victimized at higher rates than other youth. The risk of victimization tends to increase when youth are older (particularly 18 or older, even while still in a juvenile facility). Time in the facility also appears to make a difference with higher rates of victimization found when youth are incarcerated for 12 months or longer. Over two-thirds of reporters in the 2012 survey reported offending by multiple perpetrators when the victimization was youth-onyouth, and around half was believed to be gang-related. Most victimization occurs in sleeping areas, but showers, bathrooms, and recreation areas were also sites of sexual victimization, sometimes with physical force. It is worth noting that the 2012 survey was mandated by a 2003 federal law entitled the Prison Rape Elimination Act (PREA). Among other things, PREA required the USDOJ to create and issue regulations to both adult and juvenile facilities to prevent, detect, and respond to acts of sexual victimization. Although PREA is federal law, its reach applies to state and local facilities as well. Findings from the 2012 survey influenced the development of several changes to protocols. These include eliminating strip searches and pat downs by staff of the opposite sex, adding facility-wide video monitoring, enforcing minimum staff-to-resident ratios, and reinforcing the mandated reporting and investigation of incidents. Whether these new protocols have been initiated, however, is yet to be determined and appears to differ significantly from state to state. The expense of implementing these protocols is believed to be extremely burdensome on state and local systems (upwards of 2 billion dollars over 15 years) (Mandel 2015). Spending on other priorities may supplant investment in these changes, however, particularly given the relative lack of sympathy for incarcerated persons, youth, as well as adults. One of the most publicized reasons for ending the practice of placing persons under 18 in adult correctional settings is the reported danger of sexual abuse. Even during brief detention stays, youth can be victimized by staff or other inmates. For instance, in one survey, a larger percentage of youth who reported victimization experienced that victimization within 24 hours of arriving at the facility (Mandel

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2015). The most youthful inmates appear to be the ones most victimized. In adult correctional environments, girls are victimized more than boys, white youth more than Latino or black youth, and nonheterosexual youth more than heterosexual youth. Fortunately, the population of youth under 18 in adult jails has decreased markedly (around 50%) since its peak in 2010 (USDOJ, OJJDP Statistical Briefing Book).

C. Physical Victimization, Suicide, and Neglect In general, the mortality rate for delinquent youth who have been detained at all is far higher than in the general population. A longitudinal study of youth who had been detained in Cook County, Illinois (containing Chicago), showed a mortality rate after detention of four times greater for boys and eight times greater for girls, compared to peers who had not been detained (Violent Death in Delinquent Youth after Detention). Most of the post-detention deaths were due to gun homicides, with AfricanAmerican youth far more affected than other groups. Youth in residential facilities are shown to die less from accident or homicide than from suicide and illness. For youth in adult correctional facilities in particular though, mortality rates are exceptionally high. Children under 17 have been particularly vulnerable in adult correctional environments, with a mortality rate twice that of incarcerated young adults, aged 18–24, and nine times that of youth in the general, un-incarcerated population. Suicide among youth in adult jail is also shockingly prevalent compared to suicide in juvenile facilities, happening 36 times as often in adult correctional environments. Suicide as a cause of death for youth in adult correctional environments has occurred on average once a year overall in the USA since 2010 (Suicidal Thoughts and Behaviors Among Detained Youth 2016). Suicide is also an issue of concern in juvenile detention facilities. The prevalence of completed suicides among detained youth is two to four times higher than in the general, un-incarcerated population. A study in a Cook County, Illinois, detention facility found that around 10% of detained youth had considered suicide in the previous 6 months and that 11% had attempted it (Suicidal Thoughts and Behaviors Among Detained Youth 2016). Suicide attempts were more common among girls and among youth with anxiety disorders. Suicide rates are higher with detained youth for a variety of reasons. Detained youth often suffer from psychiatric disorders, many untreated and undiagnosed. In addition, separation from family and familiar environments and the experience of lockup and punishment – particularly solitary confinement – all enhance the chance that a youth will consider or attempt to take his/her own life. Physical violence and neglect involving youth in correctional environments are additional very serious concern. The Annie E. Casey Foundation, based in Baltimore, Maryland, reported on maltreatment of youth first in 2011 in a publication entitled No Place for Kids: The Case for Reducing Juvenile Incarceration. Updated in 2015, the Casey Foundation report documented widespread evidence of maltreatment in US youth detention centers including the use of solitary confinement and

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isolation and the unnecessary and excessive use of physical restraints. The report also documented unchecked youth-on-youth violence and staff violence against youth in many US facilities. This violence continues despite legal action and court orders in recent years that have attempted to address such abuses. Among the more disturbing of the documented findings is a description of a Mississippi “Training School” (i.e., residential detention facility) which was investigated by the US Department of Justice in 2003. Among other abuses, girls exhibiting acting out or even suicidal behavior were locked in “the dark room,” described as a locked, windowless cell where they were left, without clothing, for sometimes days at a time. No furniture is described as being in the room; only an open drain in the floor, serving as the only toilet. All in all, the Casey Foundation documents violent and abusive conditions in youth residential facilities in 14 states since 2000 (Mandel 2015). Lack of federal authority over state-run or supervised facilities may exacerbate abuse and neglect of youth in US correctional environments, the argument being that federal agencies such as the Department of Health and Human Services, USDOJ, and the Department of Education do not have sufficient authority with which to ensure basic standards across the 50 states and other US jurisdictions (Brown 2008). For instance, some state-run juvenile justice facilities operate without meeting any licensing requirements, and even in facilities (public or private) that are covered by licensing requirements, things such as suicide prevention are not properly addressed. In general, abuse and neglect are seen in facilities with fewer resources, overpopulation issues, and strained budgets. These three major factors plague all US states but to vastly differing extents. While conditions and practices will continue to differ among the states, an effort to ensure some degree of federal oversight, and the establishment of compliance standards, seems to hold promise for improvement.

IV. Institutional Environments and Children with Disabilities A. Overview There are heightened risks of maltreatment for any child with a disability, whether within or without an institutional setting. Given space constraints, this section focuses mostly on the risk of physical and sexual victimization to US children in institutions serving children with intellectual disabilities. This should not, however, detract from consideration children with disabilities of all kinds, particularly ones that restrict movement, control over motor skills, communication and perception, as children with these conditions are also at serious risk from maltreatment in any setting. As noted earlier, estimates of the number of children institutionalized internationally range from two to eight million (Barriga et al. 2017). Exact numbers are hard to obtain for a variety of reasons, from political circumstances to a lack of licensing and monitoring. What is agreed upon, though, is that most children growing up in institutions are children with disabilities of some kind. In the USA, recent years have

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seen a steep drop in children with disabilities housed in institutional settings. A series of revelations about abuse and neglect in US institutions in the 1970s and 1980s in particular led to the closing of many institutions designed to house and educate children with disabilities. Further, the great weight of scientific evidence suggests that at-home child rearing, with assistance if necessary, produces far better results than institutionalization. Still, many children with disabilities find themselves in institutional care at some point in their lives.

B. Sexual Victimization It is crucial to note at the outset that, at least with adults, sexual contact between a person with a disability and a person without a disability is not by definition abusive or illegal. The issue is whether the person with a disability can and does consent to the sexual contact. The age of consent differs from state to state in the USA ranging from 16 to 18 (Norman-Eady et al. 2003). Most US jurisdictions seek to avoid punishing adolescents of similar age from engaging in sexual activity, even if one or both youths are technically under the legal age of consent. Further, about one-half of US states, largely in response to the rise of the use of sex offender registries, have passed so-called “Romeo and Juliet” laws, whereby (in most cases) a person 18 or over is protected from serious legal consequences even if the person’s sexual partner is under the age of consent, as long as the victimized person is generally within 3 or 4 years in age of the accused person. Where children and adolescents with disabilities are concerned, the application of laws regarding consent and age should be the same; the only exception would be if the disability in question affects the person’s developmental or intellectual level to the extent that they cannot consent to sexual activity. All US jurisdictions forbid sexual contact with persons (i) who withhold actual consent to sexual activity (i.e., who “say no” or otherwise express non-consent) and (ii) who cannot legally consent to sex because of physical helplessness or another inability to conceptualize or fully understand what consent means. It is important to note, though, that the term “disability” can describe literally thousands of recognized physical, mental or emotional challenges, most presenting themselves across a spectrum of severity. The presence of a disability in and of itself does not prevent a child from exploring their sexuality or engaging in sexual activity any more than a child without a disability. Nor should it, provided that the behavior is developmentally appropriate. In an institutional setting for a child with a disability (as in any institutional setting), the only non-abusive sexual contact would be between children of like age and assuming both children are able to give informed, meaningful consent to the specific sexual activities engaged in. Any other type of sexual contact is abusive and should be prevented and responded to where detected. The dangers include sexual abuse from other children within the institution, from staff and treatment providers, and from visitors. Children with intellectual disabilities can be at particular risk for victimization within the institutional setting. Intellectual disabilities, among other things, can

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prevent the child from determining or expressing her own will or avoiding unwanted contact. Some intellectual disabilities result in children who are overly affectionate but unable to establish boundaries or to recognize danger or inappropriate advances. Sexual abuse is very common in situations that involve dependency. Children with intellectual disabilities are often far more dependent on others and thus socialized to adapt to others’ expectations. Like any child in an out-of-home setting, they will become accustomed to following “the rules” of staff, older children, and treatment providers. In some cases, depending on the severity of the disability, a victimized child may not perceive that the sexual abuse is inappropriate. The negative selfimage and lowered expectations of many children with disabilities (including intellectual ones) can also deter reporting. Internationally published literature estimates that the rate of victimization generally (not just in the institutional setting) is three to five times higher for people with disabilities than the nondisabled. A 2011 study conducted in the Netherlands found that 61% of females and 23% of men with intellectual disabilities had experienced sexual violence. It is also likely that rates of victimization are even higher for individuals with more severe intellectual disabilities, since their ability to report is far more limited. Within the institution, the danger of sexual victimization can be disturbingly high. Another Dutch study conducted in 2012 found that children with intellectual disabilities in residential youth care placement in the Netherlands were sexually abused at a rate three times greater than children in residential placement and without such a disability (Scharloo et al. 2016). Relatively early research was conducted on victimization of children in the deaf community within the USA. At the outset, it is important to note that many within the community of deaf or hard-of-hearing persons do not consider themselves to have a disability. Others do consider their deafness to be a disability but still consider themselves to be part of a distinct cultural group. In either case, the distinction is usually denoted by capitalizing the “D” in deaf, so that a person who identifies culturally as deaf may describe themselves as “big D deaf.” One reason for this cultural identity is quite relevant to the present topic. Thousands of deaf children in the USA (and other countries as well) were educated in residential schools for the deaf, beginning in the nineteenth century and continuing through much of the twentieth century. Largely, this was due to the fact that most deaf children were born into families where there were no other deaf family members (deafness is more commonly the result of birth trauma or early illness rather than an inherited characteristic). What followed from this was the understandable belief that deaf children would benefit greatly from being socialized with and educated around other deaf children. Whatever the positive aspects of this were, there has unfortunately been rampant sexual abuse documented within schools for the deaf over the last 30–40 years. In one 1987 survey, over half of the students in one 9th grade class reported having experienced sexual abuse (Sullivan et al. 1987). Other surveys of deaf children revealed similar rates of abuse, some of it occurring at home as well (rates of sexual abuse for deaf children has been shown to be higher than for children without hearing difficulties generally) (Vernon and Miller 2002).

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Sexual abuse within deaf residential facilities occurs for reasons typical of most institutional settings. These include isolation, relative powerlessness, a difficulty in communicating about sexual subjects, and institutional leadership that has traditionally been far more concerned with covering up child sexual abuse and protecting the institution’s name and reputation (Obinna et al. 2005). These characteristics (most notably the inappropriate institutional response) likely attracted predatory people to positions within these facilities, making the problem worse over time. International research reveals that perpetrators in cases of institutional sexual abuse are professional caregivers about 25% of the time, usually male (Rus et al. 2017). While it is a disturbing statistic, it should not be surprising. Predatory individuals often attempt to place themselves in favorable environments where they can use their power to perpetrate acts of abuse against relatively helpless victims. For this reason, institutions must insist on the kinds of straightforward guidelines all institutions should require, such as video surveillance in all appropriate areas and the requirement that adults never work alone with one or more children and that all suspicions of sexual misconduct be fully investigated with the involvement of civil authorities.

C. Other Maltreatment Risks For children with disabilities in institutional environments, the risks of abuse and physical, emotional, and educational neglect are all heightened because of the child’s circumstances. In environments that are prepared for the disability (such as therapeutic foster care), the child might fare better. This is simply because staff and caregivers are trained to deal with the disability and respond, treat, and provide care appropriately. But in an environment not focused on a particular disability, or in the common case where the child’s disability is undetected or undiagnosed in the institutional setting, the child might fare far worse. Consider a correctional institution housing a child with an undetected disability like dyslexia, autism spectrum disorder, or a behavioral disorder. Such a child might be viewed as uncooperative, unwilling to learn, defiant, or “incorrigible.” Rather than seek to understand the child’s behavior, staff, educators, and even fellow children are likely to reject it. This can cause the child to be further isolated, either socially or due to infractions of institutional rules and regulations. This kind of isolation is even more likely in a secure, correctional environment than a noncorrectional one. Indeed, discipline and the desire for control over the child are large causes of abuse and neglect for children with disabilities in institutional settings. Physical restraint of a child may be appropriate and necessary in certain circumstances for the safety of the child and those around him. Most institutions in the USA have procedures to follow when staff makes physical contact with a child other than incidental contact related to regular care (such as changing clothing or feeding). Careful documentation and a follow-up investigation for any non-incidental physical contact (such as restraint) are almost always required. But particularly in cases where the

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child’s disability affects communication or their ability to perceive or report abuse, overuse of such restraint or physical contact (even when fully documented) is a constant threat. The child’s disability, especially if misunderstood or ignored, may cause anger and frustration on the part of the caretaker. This can result in beating with objects, hands, or fists. Finally, the risk to a child with disabilities can be even greater from other children (whether the other children have disabilities or not) simply because the behavior of other children in the same environment is not nearly as regulated as that of the caregivers. A “boys will be boys” or similar attitude adopted by staff in any institutional environment can lead to torturous conditions for a child with a disability. Generally, smaller environments are safer. Children with disabilities, like all children, are more protected when the ratio of children to caregivers is low. Conversely, overburdening caretakers with too many children is often cited as a cause for maltreatment.

Key Points 1. Institutional environments are by nature less nurturing and individualized than traditional family environments. However, institutional environments can be made safer with proactive and commonsense approaches. 2. Children with disabilities are at particularly heightened risk for maltreatment, both within and without the institutional setting. Of particular concern is that many disabilities shouldered by children are undetected and/or undiagnosed until the child is already in the institutional setting and sometimes not at all. 3. Rather than attempting to “screen out” abusers and prevent their infiltration through interviews, background checks, and other means, institutions serving children are more likely to protect their charges by making the institution less attractive to predatory or other harmful people. 4. Institutions can better ensure child safety by following commonsense guidelines. They can use video surveillance, require that at least two staff members be present with children, create and publish reporting procedures for suspected maltreatment, and publicize their commitment to work with civil authorities to investigate suspected cases.

Summary and Conclusion Institutional care (and other residential settings outside of the traditional family home) is a reality for millions of children in the USA and across the planet. While imperfect for a number of highly concerning reasons, it is sometimes the only plausible alternative to life within the birth and family environment. Institutions will never replace the ideal nurturing and learning environment that parents can provide in a traditional home setting, but they can be made safer, more effective, and less traumatic. Child maltreatment is disturbingly frequent in the institutionalized

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care of children, but it is not inevitable. However, for any institution to effectively curb the abuse and neglect of children it serves, the institution must be willing to take a highly proactive and public stance. First and foremost, institutions which serve children must abandon their instinct for self-protection or preservation to the extent that it causes minimization or covering up of maltreatment. All suspected cases of maltreatment must be thoroughly investigated with civil authorities involved early in the process. Institutions must employ basic child protection strategies such as preventing adults from being alone with one or more children, even if these strategies strain resources. The use of technology such as video surveillance (now easier and cheaper to use than ever) must be employed to ensure observation and accountability. Guidelines, rules, and reporting procedures should be crafted with outside assistance from child protection experts and then publicly displayed. Efforts like these will not guarantee that an institution is not infiltrated by either a predatory person or just an incompetent, cruel, or lazy one. But it will make the institution far less attractive to those who would cause harm within it. There simply are no probing questions, interviewer’s intuition, background checks, or any other methods that will “screen out” harmful people from an institution. The far more effective means to protect the institutional environment is to make it less desirable a place for harmful people to be.

Cross-References ▶ Dental Neglect ▶ The Juvenile Justice Response to Violence

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Increasing Scope and Severity of Technology-Facilitated Child Abuse . . . . . . . . . . . . . . . . . . . . . . . Characteristics of Online Offenders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Offender Grooming Tactics in the Digital Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Survivor Perspectives: The Impact of Technology-Facilitated Child Abuse . . . . . . . . . . . . . . . . . . Emerging Issues and Trends in Technology-Facilitated Child Abuse Cases . . . . . . . . . . . . . . . . . . Sextortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Online Gaming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Live Streaming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Going Dark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Virtual Reality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Remote Cloud Storage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Encryption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points: Combatting Technology-Facilitated Child Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Escalating technological integration in everyday life has been accompanied by an exponential increase in technology-facilitated child abuse. Diverse online platforms are now utilized for exploitive purposes, the quantity of child sexual

This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. R. J. Peters (*) Zero Abuse Project, Fairmont, WV, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_20

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abuse material in existence has skyrocketed, and offender anonymization strategies continue to increase in sophistication. The quantity alone is staggering; technology companies reported a record of 45 million images and videos explicitly depicting child sexual abuse in 2018. This chapter will review literature and practitioner insights into the increasing scope and severity of child sexual abuse material and present demographic characteristics of those who perpetrate technology-assisted crimes against children. It will then describe hands-on offender grooming strategies and their analogues in the digital age; survivor perspectives on the impact of child sexual abuse material distribution; and finally, emerging issues and trends in this field, including sextortion, live streaming, gaming platforms, the dark web and other anonymization methods, virtual reality, remote cloud storage, and encryption. The chapter will conclude with recommendations in combatting technologyfacilitated child abuse. Keywords

Child pornography · Child sexual abuse material · Dark web · Encryption · Going dark · Grooming · Peer-to-peer (P2P) network · Sextortion · Solicitation · Tactical polygraph

Introduction Child sexual abuse material has become exponentially more accessible in recent years, increasing drastically in both quantity and severity. This chapter will review literature and practitioner insights into the scope and severity of child sexual abuse material, including the staggering number of known images and videos reviewed by law enforcement and nonprofit entities annually; the strong trend toward younger victims, including infants and toddlers; and the growing severity and violence of the depicted sexual exploitation itself. Demographic characteristics of those who perpetrate technology-assisted crimes against children will be briefly reviewed, as well as possible explanations for demographic trends. Some of the literature’s limitations are also examined. The chapter will discuss models of hands-on offender grooming strategies, and their parallels in the digital world, with insights from perpetrator interviews in existing literature. Offenders take full advantage of the disinhibition dynamics of online interaction, ubiquity of Internet usage by children, and the minimal to nonexistent online supervision of many minors. Specific vulnerabilities that offenders seek to exploit will be discussed in the context of relevant online platforms, with an emphasis on methods of manipulation and the tactics of perpetrators who make no attempt to mask their intentions, even while communicating with minors. Survivor perspectives on the impact of child sexual abuse material distribution will be briefly discussed, followed by a discussion of several emerging issues and trends in this field, including sextortion, live streaming, gaming platforms, the dark

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web and other anonymization methods, virtual reality, remote cloud storage, and encryption. The chapter will conclude with recommendations in combatting technology-facilitated child abuse.

Increasing Scope and Severity of Technology-Facilitated Child Abuse Technology is now woven into the fabric of everyday existence. The US Supreme Court has referred to cell phones as “almost a ‘feature of human anatomy’” (Carpenter v. U.S., 2018), which contain the “privacies of life” (Riley v. California, 2014). The intricate connection of technology to almost all facets of life is no different for individuals who seek to exploit children – of which there are many. Dr. Michael Seto has opined that the upper limit of pedophilia prevalence in the general male population is 5% and prevalence estimates in other studies range from 3% to 9.5%, with the true prevalence “being unknown in the absence of epidemiological research” (Seto 2013, p. 27). With the increase of everyday technological integration has come an exponential increase of technology-facilitated child abuse. The threat has increased in a variety of ways, from the diversity of online platforms utilized, to the quantity of child sexual abuse material in existence, to the enhanced sophistication of offender anonymization strategies. The quantity alone is staggering. In 2018 alone, 45 million photos and videos were reported by tech companies as explicitly depicting child sexual abuse (Dance and Keller 2019b). The flood of images is becoming increasingly prevalent. In 2004 the National Center for Missing and Exploited Children (NCMEC) reviewed 450,000 files depicting child sexual abuse; in 2015, they reviewed 25 million files. NCMEC, like law enforcement vendors and tech companies, relies on PhotoDNA concepts to process such massive amounts of media. At a granular level, software strips uploaded images of their color and forces them into a square shape for consistency of image comparison (Dance and Keller 2019c). Next, software algorithms identify borders within the image and place a grid over the results (Dance and Keller 2019c). Each square within this grid receives a value based on its appearance; the combination of all image grids results in a digital “fingerprint” for the image (Dance and Keller 2019c). This value can then be compared against the values, or digital fingerprints, of confirmed child sexual abuse material (Dance and Keller 2019c). From 2007 to 2013, NCMEC experienced an increase of 5,000% in the number of child exploitation images reviewed (Hennessey 2017). In 2018 the National Center for Missing and Exploited Children’s (NCMEC) CyberTipline received over 18.4 million reports of suspected online sexual exploitation of minors (NCMEC 2019c). NCMEC also administers the Child Victim Identification Program, which has reviewed over 293 million images and videos since 2002 and resulted in the identification of over 17,500 minor victims (NCMEC 2019a).

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This material is frequently labeled “child sexual abuse material” or “child sexual exploitation material,” depending on the depicted acts, terms which are preferred by the United Nations and various international bodies and nonprofit organizations (UNODC 2019; Hennessey 2017, n. 2). These organizations maintain that the common term “child pornography” minimizes the violence perpetrated on the child, arguably shifts blame from the perpetrator to the child, and implies that the activity was consensual. Despite these valid concerns, the term “child pornography” is prominent in many legal instruments, relevant literature, and state statutes, and for the sake of clarity, these terms will be used interchangeably throughout this chapter. The number of images of child pornography on peer-to-peer (P2P) networks greatly exceeds the quantity of known, identified perpetrators (Seto 2013). These networks of computers, made popular by services such as Napster, Gnutella, and LimeWire, allow files and folders to be shared with specific users or with the general public (PCMag 2019). Two Department of Justice investigations of a select few P2P networks uncovered “over 20 million unique internet protocol (IP) addresses accessing known child pornography files” (Seto 2013, p. 25). Child exploitation material is ubiquitous on peer-to-peer file-sharing systems. One analysis of search terms in a peer-to-peer network concluded that three of the top terms were references to child sexual abuse material, two of which were explicit references (Seto 2013, p. 21). Statistics from the criminal justice system also reflect the exponential increase of illicit online activity. In 2009, arrests for Internet sexual crimes were triple the number of those from a decade earlier (Seto 2013). From 2012 to 2015, the Department of Homeland Security’s Operation Predator resulted in the arrest of over 8,500 perpetrators and identified 3,259 minor victims (National Strategy 2016). From 1994 to 2006, federal prosecutions of child sexual exploitation increased by 82.8% (National Strategy 2010). From 2010 to 2014, federal indictments increased 31% (National Strategy 2016). These trends are not unique to the United States. In 2010, the United Nations Children’s Fund (UNICEF) estimated that over four million websites depicted child sexual exploitation (National Strategy 2010). A July 2009 United Nations report estimated that 750,000 predators were actively engaged in attempting to use the Internet to sexually exploit children – now “the number is not considered measurable” (Hennessey 2017, p. 4). Quantity is not the only aspect of this crisis to escalate – the violence and youth of victims are also intensifying (Hennessey 2017). It is now considered commonplace for child exploitation investigations “to include files depicting the sexual exploitation of infants and toddlers” (National Strategy 2016, p. 143), and reported images include victims “as young as days old” (National Strategy 2016, p. 72). The Department of Justice maintains that the increase in availability of exploitative content has resulted in increasingly sadistic and violent images (National Strategy 2010, p. 22). This position is bolstered by a 65% increase in federal sentencing enhancements for “sadistic, masochistic, or violent images” between 2002 and 2008 (National Strategy 2010, p. 22). International law enforcement has also observed increasingly severe acts and younger child victims (Bronskill 2016). The National Association to Protect Children maintains that 83% of those who possess child

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sexual abuse material seek images of prepubescent children; 80% seek depictions of child rape; 39% are interested in images of toddlers; and 21% seek depictions of child torture (NAPC 2019). Seventy-eight percent of images and videos analyzed by the CyberTipline depict children under the age of 12 (Thorn 2019). It has been estimated that less than 2% of related investigative leads are investigated (NAPC 2019). Studies of online offenders frequently report a lack of prior criminal history, demonstrating that most who are convicted have likely offended with impunity in the past (Webster et al. 2012). For example, most offenders in one sample of 290 offenders were never criminally charged, “though 95% admitted they had viewed child pornography at some time in their lives (some quite frequently)” (Seto 2013, p. 21; Riegel 2004). In a separate study, three quarters of child pornography offenders in the sample group had no criminal record (Neutze et al. 2011). A leading scholar reports that “only some cases will be thoroughly investigated and prosecuted” (Seto 2013, p. 22) due to lack of resources and prioritization of other cases. Law enforcement has often responded to the epidemic of cases by choosing to investigate those with younger victims. One detective remarked that “We go home and think, ‘Good grief, the fact that we have to prioritize by age is just really disturbing’” (Dance and Keller 2019a). Former Attorney General Eric Holder referenced the “historic rise in the distribution of child pornography, in the number of images being shared online, and in the level of violence associated with child exploitation and sexual abuse crimes. Tragically, the only place we’ve seen a decrease is in the age of victims” (Holder 2011).

Characteristics of Online Offenders It is often difficult to meaningfully distinguish “hands-on” contact sexual offenders from online-only offenders. The groups frequently overlap. So-called tactical polygraph tests have been administered to online offenders almost immediately after law enforcement’s first contact. These polygraph tests gather additional information outside of the initial offense, such as details of prior offenses against children or the suspect’s broader history (Bourke et al. 2015). Frequently, subjects thought to be noncontact offenders confess to hands-on offenses during these polygraph tests. The literature suggests typical characteristics of online offenders. Online offenders are overwhelmingly male, even in comparison with contact offenders, a population that is also dominated by males (Seto 2013, p. 144). Despite women’s underrepresentation in the literature, survey data suggests that “some women view child pornography,” and the existence of women in roles of authority who perpetrate sexual offenses against young adolescents “suggests some women do contact adolescents online for sexual purposes” (Seto 2013, p. 145). One study found that online offenders are generally younger and better educated than contact sex offenders. This may reflect the correlation of Internet usage with educational attainment and youth. As Internet access increases across sociodemographic categories, this characteristic may diminish or disappear (Seto 2013,

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pp. 145–146). Online offenders are far more likely to be Caucasian than contact sex offenders, and ethnic differences in Internet usage do not appear to clearly explain this (Seto 2013, pp. 146–147). They are also “less likely to have ever been married,” which may reflect “the prominent role of pedophilia and hebephilia in child pornography offending,” since those who are sexually attracted to minors “are less likely to enter adult relationships” (Seto 2013, pp. 146–147). In three studies, contact sex offenders scored lower on measures of victim empathy than online sex offenders (Seto 2013, p. 150). Importantly, child pornography offenders “showed significantly greater sexual arousal to children than to adults,” even when compared with a group of 178 sex offenders with child victims, leading Seto et al. (2006) to conclude that “child pornography offending might be a stronger diagnostic indicator of pedophilia than sexually offending against a child” (Seto 2013, p. 151). Perhaps this is due to the phenomenon of “some nonpedophilic men opportunistically offend[ing] against children,” including “antisocial men who seek sexual gratification from adolescents who show some signs of sexual development but are below the legally defined age of consent” (Seto 2013, p. 151).

Offender Grooming Tactics in the Digital Age Given the similarity of tactics deployed by abusers in both online and in-person contexts, a brief review of the literature exploring in-person grooming tactics is instructive. Grooming is defined by the Office of Sex Offender Sentencing, Monitoring, Apprehending, Registering, and Tracking (SMART) as “a method used by offenders that involves building trust with a child and the adults around a child in an effort to gain access to and time alone with her/him” (ABA 2016, para. 5). Researchers have identified multiple distinct stages in the grooming process (Spraitz and Bowen 2019, p. 708), although sexual offenders are not a homogenous group and may not all follow this process exactly (Webster et al. 2012, p. 39). The first stage is victim selection. In this stage, offenders consider various factors in selecting a potential victim, such as psychological vulnerability, victim attractiveness, reduced supervision of the child by adults, familial conflict, and substance abuse (Spraitz and Bowen 2019, p. 708). The Netflix documentary “Abducted in Plain Sight” (Borgman 2017) demonstrates how one offender fostered and leveraged familial conflict throughout the grooming process. The perpetrator, Robert Berchtold, exploited weaknesses in Bob and Mary Ann Broberg’s marriage and made separate, successful sexual advances on both, resulting in a favorable power dynamic that he utilized to abuse their child (Borgman 2017). Perpetrators may also consider familial substance abuse in the selection process, because it increases children’s vulnerability. The second stage involves obtaining access to the child (Spraitz and Bowen 2019, p. 709). In the overwhelming majority of sexual abuse cases, victims know the offender. In this stage, perpetrators typically manipulate and build trust with the adults surrounding the child, both to enable access to victims and reduce the

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likelihood of the victim being believed in the event of an allegation (Spraitz and Bowen 2019). As perpetrators become more ingrained in relevant social circles, they isolate the victim to increase dependence on them, create a sense of shared responsibility for the abuse itself, and further reduce the likelihood of reporting (Spraitz and Bowen 2019). Isolation may initially appear to others as positive attention, extensive mentoring, or quality time. The third stage involves manipulation to create trust, using such strategies as gift-giving, playing games, and providing alcohol and/or drugs (Spraitz and Bowen 2019). There is some evidence to suggest that familial contact offenders were more likely to give victims gifts, while extrafamilial contact offenders were more likely to provide alcohol and drugs (Spraitz and Bowen 2019). One survey demonstrated that offenders were more likely to play games, teach activities, bribe, and provide transportation than to demonstrate affection (Spraitz and Bowen 2019). The fourth stage “involves gradually increasing physical contact to desensitize the victim” (Spraitz and Bowen 2019). Physical touching tends to be utilized prior to sexual touching (Spraitz and Bowen 2019; Abel et al. 1998). In 1988, one study observed that “75% of intrafamilial and 56% of stranger perpetrators in their sample used accidental touching as a grooming strategy. It was the abuser’s intent that the purposeful touch appears to be an accident” (Spraitz and Bowen 2019). Perpetrators have modified the grooming process for a digital age, which has fueled an exponential increase in online exploitation of children. Internet-based grooming strategies present numerous challenges to law enforcement, with offenders taking advantage of the “relative anonymity” of online interaction, minimal to nonexistent online supervision of numerous minors, or the child’s belief that the offender is trustworthy or a friend (ICMEC 2017). Online grooming often includes the use of child sexual abuse material (ICMEC 2017, p. 1), with offenders manipulating or coercing children into sexually explicit activities through the Internet. The ubiquity of Internet usage among even young children provides ample opportunities for access, grooming, and exploitation by predators. The social spheres of children span “both the virtual and the non-virtual worlds” without any clear dividing line (Brå report 2007). In one Swedish study, over 30% of surveyed 15-year-old youth reported “some form of sexual contact [online]” within the past year with “a previously unknown person that they knew or believed to be an adult” (Brå report 2007). The vast majority of these youth were contacted through the Internet (Brå report 2007, p. 7). There was a significant gender gap in this reporting (48% of girls reported sexual contact, compared to 18% of surveyed boys) (Brå report 2007, p. 7). Additionally, 51% of girls reported receiving “a sexual contact via the internet from a person who was at least five years older than them,” and 33% indicated that this occurred prior to them turning 15 (Brå report 2007, p. 8). In nearly 40% of reported incidents, previously unknown perpetrators “succeeded in extending contact” with the victim outside of the Internet (Brå report 2007, p. 11). Importantly, “very few youths” reported sexual contact with adults exclusively offline – which is a sobering indication for the primacy of technology in grooming sexual abuse victims (Brå report 2007, p. 7). There is evidence to suggest that online solicitation is increasing. In 2005, a US study demonstrated that 1 in 25 children was

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sexually solicited by online offenders; in 2010, this increased to 1 in 11 children (ICMEC 2017, p. 3). Grooming occurs in a growing variety of online contexts: social media, chat rooms, gaming platforms, photo sharing websites, instant messaging applications, and others (ICMEC 2017, p. 2). These contexts grant offenders the ability to create personas, connect with children, and gain their trust (ICMEC 2017, p. 3). For example, some offenders in sextortion cases posed as peers to obtain initial compromising media, which they leveraged to coerce child victims into additional explicit acts. The proliferation of mobile and social media apps has provided additional avenues for perpetrators to engage in online exploitation, even with more mainstream apps such as Facebook, Instagram, Snapchat, and YouTube (Evans 2019). Offenders prefer social media websites for online grooming. Social media websites have several advantages for grooming. These websites enable offenders to follow their sexual preference for a boy or a girl. They also provide voluminous information about the child, such as name, school, and demographic information, interests (e.g., popular movies and music), communication style, social vulnerabilities, and insecurities (ICMEC 2017, p. 3; Webster et al. 2012). Even the child’s screen name itself can provide useful information, as it sometimes enables the offender to follow both a sex and age preference (e.g., sara14 or jon2009) (Spraitz and Bowen 2019, p. 708). Child sex traffickers may also prefer social media platforms, since they foster gradual development of trust and perceived intimate relationships or friendships, enabling tactics of manipulation, coercion, control, and isolation (ICMEC 2018, p. 2). The Internet and related technologies are becoming “the predominant mechanism” by which children are “forced into modern-day enslavement for sexual purposes” (ICMEC 2018, p. 2). The flexibility of online communication enables offenders to target a few children at a time or many children simultaneously (Webster et al. 2012). One convicted offender estimated that he was chatting with about two thousand individuals, “about seven hundred and fifty [of whom] were young girls age 14 to 15” (Webster et al. 2012). Online grooming processes often mirror in-person grooming strategies. For example, offenders almost always begin grooming by “scanning the online environment to make an ‘informed’ decision about who to approach for sexual contact” (Webster et al. 2012, p. 45). One study documented an offender’s tendency to utilize online forums and chat rooms “for text-only” interaction with potential victims, which would continue until the exchange ended “or escalated into a physical meeting” (Webster et al. 2012, p. 48). Manipulation is prevalent in online as well as in-person grooming. To quote one offender, “You have to continue manipulating. Dig deeper, see what sort of experiences she’s had, find out where she lives, whether she has a boyfriend” (Webster et al. 2012, p. 52). As this quote reflects, predators are interested in the vulnerability and social isolation of potential victims. Online offenders target insecurities. Consider one offender’s assertion that “She had a very low self-esteem of herself because she was slightly overweight. She’d always say ‘oh I’m really fat, I’m ugly’ and I would say ‘no you’re not, you’re good looking’, I was very supportive” (Webster et al. 2012, p. 52). Frayed social connection and gaps in familial support are regularly exploited in both online and in-person

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contexts. One offender claimed that “Her parents were divorcing and so I was trying to comfort her”; another explained how “. . .a couple of boys. . . wanted a father figure and they saw me as a sort of father figure, as it were. It was the way they said things, calling me ‘daddy’ and stuff like that” (Webster et al. 2012, p. 53). Standard flattery is also in the online offender’s toolkit: “Mostly I influenced them by giving compliments and then I could steer the conversation my way” (Webster et al. 2012, p. 52). Portraying sexual activity as innocent or a game is another standard strategy that appears in both in-person and online contexts. For example, an offender who sexually exploited multiple male victims aged 5–12 described mutual masturbation as a competition: “And they would say ‘I’m getting hard, and that type of thing. . . And we would both wank together. . . we would have a competition to see who could come first, you know?’” (Webster et al. 2012, p. 56). Sexual “jokes” as a precursor to explicit behavior are also common: “There was the point where I thought, okay, well I say a joke about having ‘a big black penis in my pants, do they want to see it’ and they said yes, okay, that’s why I thought okay [sic]” (Webster et al. 2012, p. 56). It should be noted that the offender rhetoric in several of these examples falsely places the offender in a posture of passive response, portraying the socially isolated children as relational aggressors, which is common in statements by offenders. Gift-giving is another grooming tactic that has been deployed online, often in order to maintain contact with victims. For example, the offender may purchase webcams, phones, or accessories for the child. One offender said “. . .it was. . . just a gift, but maybe it was so I could carry on chatting to her” (Webster et al. 2012, pp. 56–57). Giving such gifts advances “sexual disinhibition via webcams” (Webster et al. 2012, p. 57). Offenders in chat rooms often focus on sexualized screen names or forum tags to identify potential victims. As one offender explained, “I’d always aim for someone with a sexy name because obviously, they’d be into sex” (Webster et al. 2012, p. 45). Sometimes offenders carry on several conversations at once but then become focused by sexual escalation in one conversation that is making them aroused. As one offender explains, “If one was becoming a sexual chat, then the others would start to fall off. My responses would become too slow and the young people would say ‘look you’ve obviously got other things on your mind, you’re obviously busy, we’ll chat later” (Webster et al. 2012, pp. 51–52). As with in-person grooming (Spraitz and Bowen 2019, p. 708), online offenders’ preferences for certain types of children influenced which children they selected for grooming. Offenders often look for specific physical characteristics and may insist on photographs from victims to ensure their preferences are met: “The girls I was interested in, they had to look mature enough” (Spraitz and Bowen 2019, p. 708), said one offender. Another offender said he preferred youth aged 14 or 15 since they were “more physically developed” and “younger people [were] too young” (Spraitz and Bowen 2019, p. 708). Seeking older minors is a way some offenders minimize the offense and seek to distance themselves from other offenders, who they portray as severe or immoral in contrast to themselves. Some scholars make a distinction between those who engage in online grooming and those who make “little or no attempt. . . to mask an explicit desire for sexual

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contact with young people” (Webster et al. 2012, p. 46). This distinction is evidenced in part through methods of solicitation: “I said I was interested in young girls hoping out there that might be some young teens out there that were curious”; “I wasn’t trying to say look I’m a cool guy and I understand all about teenagers. . . I was being honest, ‘I’m a 36 year old guy and I like young girls’” (Webster et al. 2012, p. 48). One offender “posted a picture of their flaccid penis as their avatar,” and others used sexually explicit screen names alongside their genuine name, age, and occupation (Webster et al. 2012, p. 48). Some offenders will be explicit with youth regarding their sexual intentions: “I’d just go online and say straight out ‘what’s your name, what’s your bra size’. And they would reply back with a size and I’d say ‘that’s nice and big. . .’” (Webster et al. 2012, p. 52). Some online offenders are impulsive (SOMAPI 2017, p. 68), and many are efficient in their grooming behaviors. An international study determined that offenders “often introduce sexual topics after just three minutes” and posited that “a bond can be formed” with a target after 8 min (INHOPE 2012). The Online Grooming Communication (OGC) project conducted 2 studies of over 250 individuals exhibiting grooming behavior and discovered that some offenders arranged inperson meetings in as little as 18 min with individuals they believed to be children (Davis 2016). One European study examined the ways in which offenders altered their identity to facilitate grooming. Some offenders described minor changes: “I said I had an athletic body rather than skinny, but otherwise my profile was true”; “The only thing on my profile that was not true was that I said I was more social than I actually was” (Webster et al. 2012, p. 47). Perpetrators thoroughly manipulated their identity in an attempt to portray themselves more attractively to children: “. . .sometimes I got negative reactions and was called a ‘paedo’ . . .so I then used a younger age as girls were more likely to respond to me” (Webster et al. 2012, p. 47). Other offenders enjoyed being brazenly deceptive: “You can put any picture up and say it’s you, you can invent all sorts of stories. I got a kick out of it. The manipulation is part of the game. Why? You’re certainly not going to come out and say ‘I’m 30 years old and I would like to get to know you’” (Webster et al. 2012, p. 47). Some offenders engaged in layered chatting schemes, creating multiple identities to boost their credibility and believability: “I sometimes created a new identity and would speak to the victim as real and fake me. That way I could transfer information about me through two channels. I would typically pretend to be a younger girl as girls tend to talk more openly and honestly to other girls” (Webster et al. 2012, p. 47). One offender in this study took on the persona of the targeted victim “and pretended to be her to her friends,” in order to discover “information about the girl that she would not share” when the offender asked her directly (Webster et al. 2012, p. 47). Offenders often strategically used age-appropriate language and emoticons to dialogue effectively with minors. One offender in his late 40s typed the phrase “OMG no u didn’t!” in response to a minor who disclosed a fight with her mother. Offenders sometimes utilized emoticons with temporal or regional significance: “If it was someone’s birthday I would put a birthday cake up, or if they were from America I’d pull up a stars and stripes symbol” (Webster et al. 2012, p. 53).

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As with in-person offenses, explicit photos and videos are utilized to acclimate the victim to sexual content and topics and ultimately sexually abusive acts. These are often used as sexual conversation starters: “I’d send them through and we would comment. . . on the person in the image. . .whether they were attractive or not. . .and maybe talk about what I wanted to do. . . with the girl and sometimes we had conversations about, even with the young girls about what I want her to do with, with the young girl as well or want her to do with me and what the three of us could do together. . .” (Webster et al. 2012, p. 54). Offenders utilize sexual imagery “to intensify the abuse process” and frequently describe “masturbating to ejaculation whilst discussing images with young people,” a behavioral response described as “strengthening the need to offend by some men” (Webster et al. 2012, p. 54). Utilizing sexual imagery is a very common tactic. For example, a Canadian CyberTipline examined 264 cases of online grooming and found that perpetrators “requested sexual images in 93.4% of cases.” In 30% of these cases, victims sent the requested images; suspects either sent or displayed sexual images of themselves via webcam in 35.5% of cases (CCCP 2012).

Survivor Perspectives: The Impact of Technology-Facilitated Child Abuse Perpetrators of technology-facilitated child abuse often disseminate photographic images of the abuse online, increasing the trauma for victims. One victim’s father filmed his sexual assaults of her, and the images were posted and widely disseminated online. She explained that “You’re just trying to feel O.K. and not let something like this define your whole life. But the thing with the pictures is — that’s the thing that keeps this alive” (Dance and Keller 2019a). Survivors describe “knowing that so many men have witnessed and taken pleasure” from the abuse as “excruciating” (Bazelon 2013). “You have an image of yourself as a person, but here is this other image. . . You know it’s not true, but all those other people will believe that it’s you – that this is who you really are” (Bazelon 2013). Statements from other survivors reflect the intensity of trauma from image distribution: “My pictures that are on the internet disturb me more than what Matthew did because I know that the abuse stopped but those pictures are still on the internet” (Allen and Grace 2006). Children “know that images have been made of their abuse, and they are constantly afraid that people will see those images” (Talamo 2017). Learning that their images have been utilized to groom other children is also devastating. In one study of survivors, 70% indicated that “they worry constantly about being recognized by someone who has seen images of their abuse” (CCCP 2017, p. 7). 30% indicated that they actually were “identified by a person who had viewed” the images (CCCP 2017, p. 7). Michael Reagan, son of the former President Ronald Reagan, is a survivor of child sexual abuse, some of which was documented through the production of child sexual abuse material. Reagan recalls being “deathly afraid that those photographs would come out and hurt my father’s political career. I was bearing the burden for my

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abuser, and that is what victims of child abuse are forced to do. It’s despicable what children are put through by these predators and then they spend their lives suffering because they were innocent victims targeted by evil” (Elam 2015).

Emerging Issues and Trends in Technology-Facilitated Child Abuse Cases Sextortion In recent years, sextortion has emerged as a distinct exploitative crime, “in which non-physical forms of coercion” are used to obtain sexual images or acts from children. This is commonly done by obtaining sensitive information or photos from a child and then leveraging these to coerce the child to produce additional (often increasingly severe) images or engage in additional acts, under threat of publicizing compromising images online, in the child’s social circles, or to adults in the child’s life (NCMEC 2019). Sextortion may be perpetrated in isolation or in conjunction with online grooming behaviors or other forms of sexual victimization and manipulation. One offender explains the consequences of victim hesitancy: “If she breaks my trust, I’ll threaten that I could play dirty tricks on her. For example, I could say: ‘Everything you did in front of the webcam, well I made photos, I’ll post them all on a website. . .’ They’re afraid and they realize they’ve been had. They can break out crying,” and “some go into a panic” (Webster et al. 2012, p. 58). Tragically, such threats appear to be commonplace; a Canadian CyberTipline examined a few hundred cases of online exploitation and discovered that in 24% of luring cases, the victim was threatened into compliance (CCCP 2012). The offender threatened a variety of different actions, including distributing the victim’s images on social media or to a list of damaging contacts (such as parents), initiating cyberattacks on the victim’s devices or online accounts, or attacking the victim in person.

Online Gaming Online gaming has advanced to include messaging platforms and photo and video sharing. As a result, gaming platforms’ real-time textual and visual communication is increasingly utilized by offenders to target children. One study suggested that this strategy is typically “used by men who were attempting to groom young boys,” given the perceived gender preference of minor males for video gaming (Webster et al. 2012, p. 50). As an added benefit to perpetrators, video gaming appears to “reinforce the fantasy, or ‘unreal’ aspect of what is clearly offending behavior” (Webster et al. 2012, p. 50). Another advantage of using gaming to groom victims is the ability of an offender to use their experience points and “considerable online scores as a way to ‘attract’ and open up conversations with some young boys” (Webster et al. 2012, p. 50).

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Aside from the technology itself and the ease of immediate communication, online gaming inherently creates several dynamics that are favorable to offender strategies. For example, gaming provides the offender and the target a common interest, which overcomes some initial barriers to communication (ICMEC 2017, pp. 3–4). Minimal adult supervision (which is often the reality for gaming sites) enables an offender to easily and covertly earn the child’s trust (ICMEC 2017, p. 4). Once trust has been developed, perpetrators often redirect children to other online platforms, such as messaging or live-streaming applications, to facilitate private communication and sexual exploitation (ICMEC 2017, p. 4).

Live Streaming Offenders often utilize webcams or other means of live streaming in conjunction with grooming (Webster et al. 2012). In addition to purchasing their own webcams, they may ship webcams to current or potential victims. Webcams may be used to display the child’s or adult’s genitals; to facilitate live, mutual masturbation; or to exploit multiple children at once. As one offender described a typical process: “I was at home and had the opportunity to get on the internet quickly, and she happened to be on there. And so, you know, it sexually aroused me. So I said ‘do you want to see my webcam’ and she said she did. She didn’t have a webcam, she just watched me. I just typed about what I’d like to do to her, and masturbated on the webcam” (Webster et al. 2012, p. 49). Webcam video is frequently used to view victims live, “to avoid producing or storing images or videos that could later be discovered by law enforcement” (Webster et al. 2012, p. 49). Offenders often request specific acts or clothing in this medium, e.g., “I would ask her to go on web-cam ‘with a short skirt on’” (Webster et al. 2012, p. 55). Offenders frequently request live masturbation or sex acts to be performed on the victim(s) via webcam (Webster et al. 2012, p. 55). When the perpetrator purchases a webcam, child victims can find it increasingly difficult to deny demands to appear online (Webster et al. 2012, p. 55). Offender requests for webcam interaction may be persistent and aggressive. One analysis of 166 chat logs noted “repeated” webcam invitations, “sometimes occurring up to 30 times,” often followed by perpetrators’ stated desires to meet in person (CCCP 2012). Many offenders have created opportunities for individuals to watch the live abuse of a child via video streaming services. The real-time nature of these live streams and their lack of forensic artifacts make it difficult for law enforcement to detect them (Hennessey 2017).

Going Dark Anonymization technology has increased in sophistication and mainstream access, facilitating the process of “going dark” to hide online criminal activity, communication, and associated physical location. (“Going dark” refers to a “phenomenon by

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which the government has a legal right to access data but lacks the technical or practical ability to do so” (Hennessey 2017)) This is accomplished through use of virtual private networks, dark web browsers, and encryption, among other techniques. Increased publicity for dark web technology has probably brought it to the attention of more offenders, who benefit from being on the “cutting edge of technology” to remain concealed (Dance and Keller 2019a). Perpetrators share information in secure online communities, including grooming strategies and methods for recording and sharing abusive images and videos. Some forums require that submitted images include children holding up signs “to prove the images are fresh” (Dance and Keller 2019a). Anonymity emboldens offenders, as shown by law enforcement reports of “the most violent and sadistic acts perpetrated against the youngest victims,” including infant and toddler torture and rape, appearing extensively on the Tor anonymous network (Hennessey 2017; National Strategy 2016, pp. 73–74). Anonymization networks, frequently accessed via dark web browsers, present significant investigative challenges. One popular network, Tor, “conceals the IP address of the computer visiting a website,” rendering it impossible to discover the physical location of the computer (Hennessey 2017, p. 8). Tor also offers “hidden services,” enabling users to host websites and offer services while hiding pertinent locations. These hidden services cannot be located with standard search engines. Instead, users must know the specific address to access the site through the Tor browser. This technological structure has facilitated the exchange and production of child sexual abuse material as well as “discussion, normalization, and exchange of advice about hands-on abuse of children” (Hennessey 2017, pp. 8–9).

Virtual Reality Virtual reality adult pornography is already mainstream, providing “a first-person point-of-view system” (Maxim et al. 2016, p. 61). This technology has been augmented in some cases with teledildonics, sex toys which “can be programmed to respond to an individual’s movements or the feedback from a computer game, video or livestream” (Maxim et al. 2016, p. 61), creating a sexual experience that can be controlled and/or participated in by a remote partner. Teledildonics essentially connects compatible sex toys via the Internet and enables long-distance sex between individuals (Wakeman 2017). It takes minimal creativity to see how this technology poses significant concerns in the context of child exploitation, with one researcher voicing concerns that the “intimacy and realism” of virtual reality may be capable of turning “an online offender to an offline offender” (Maxim et al. 2016, p. 61). The purpose of virtual reality is to “live the experience” (Maxim et al. 2016, p. 61), and it is likely that producers (and consumers) of child sexual abuse material will embrace virtual reality and teledildonic platforms due to the “far more interactive experience” (Maxim et al. 2016, p. 68), and resulting market shifts (Maxim et al. 2016). Researchers believe

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these platforms have been implemented in conjunction with prostitution, digital brothels, sex tourism, and voyeurism and will soon be implemented more broadly in these contexts (Maxim et al. 2016, pp. 67–69).

Remote Cloud Storage One trend in the technology industry is to shift data storage from the devices themselves to remote cloud accounts that can be accessed anywhere in the world via an Internet connection. This poses a challenge to law enforcement, since the phenomenon enables individuals to access contraband without actually storing it in their homes or on their physical devices. Significant statutory protections exist for stored communications, making it difficult for law enforcement to access this information while still complying with federal and state law. Law enforcement also encounters exigent circumstances, a legal term which refers to emergency situations, such as impending danger to life or destruction of evidence. Remote cloud storage presents special challenges, because suspects may be able to remotely wipe their cloud storage before law enforcement has authorization to access it. Though accessing information from cloud accounts through devices used by a suspect is easily done, without adequate legal authority, unwitting investigators may unintentionally violate federal law (Remy 2019). The Stored Communications Act, 18 U.S.C. 2701 et seq., provides permissible methods for obtaining pertinent electronic records, such as a search warrant or the consent of account holders. If an investigator obtains a search warrant that does not grant the ability to access the content of a cloud account and subsequently swipes down to refresh the email application on a suspect’s mobile phone, thereby uploading new emails from the cloud account to the phone, he has potentially violated federal law. Forensic examiners typically have access to technology that can obtain data from cloud accounts during the examination of suspects’ devices; but if they go beyond the scope of the search warrant, there may be significant criminal and civil penalties. Prosecutors and investigators must be aware of these challenges and coordinate the filing of legal process to comply with statutory mandates as the technology continues to evolve.

Encryption Further complicating these issues is the trend of coupling encryption with remote cloud storage. Encryption is the translation of data into another form, enabling only those with access to a key to comprehend the data (Lord 2019). This process can be extremely complex; in one case, authorities noted that it would have taken “trillions of years” to crack the child pornography website administrator’s 41-character key, which was used to encrypt the website (Dance and Keller 2019a). Encryption is recognized by offenders as an essential tool to perpetrate crimes with impunity. One dark web site dedicated to child sexual exploitation even featured tutorials on safely encrypting and sharing sexual abuse material without

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detection by law enforcement (Dance and Keller 2019a). It is often utilized to mask increasingly horrific material. One recent collection of encrypted videos depicted an adult woman inserting an ice cube into a young girl’s vagina, taping her mouth shut, suspending her upside down, and beating, slapping, and burning her. According to law enforcement, the “predominant sound” of the video was the child’s screams and cries (Dance and Keller 2019a). Perpetrators are well aware of, and emboldened by, this heightened security, with both research and law enforcement observations noting that encryption and other anonymization mechanisms fuel “trends toward more depraved and violent offenses” and “younger victims by eliminating the inhibiting fear of being caught” (Hennessey 2017, pp. 7–8). Facebook has announced plans to encrypt its messaging service, which in 2018 generated 12 million of the 18.4 million reports of online child sexual exploitation (Dance and Keller 2019a). It is believed that “this will lead to vast numbers” of exploitative images, videos, and actions “going undetected,” something Facebook’s chief executive, Mark Zuckerberg, appears to acknowledge; in his words, “Encryption is a powerful tool for privacy, but that includes the privacy of people doing bad things” (Dance and Keller 2019a). One Europol official has stated that if Facebook does encrypt its messaging service, the “possibility to flag child sexual abuse content will disappear” (Valentino-DeVries and Dance 2019). Importantly, even if law enforcement manages to detect offenders or suspect material, accessing the perpetrator’s device to obtain evidence of criminal acts is “exceedingly difficult and often impossible” if the devices are encrypted (Hennessey 2017, p. 7). Obtaining a conviction without accessing illegal images is impossible in most cases. Even if the State successfully prosecutes a given offense, an inability to access the evidence prevents prosecutors from establishing prior offenses, the full scope of perpetrators’ sexual deviance and illicit activity, or the identity of victims (Hennessey 2017, p. 7). The existence of a search warrant and law enforcement compliance with the Fourth Amendment becomes irrelevant when companies provide “forms of encryption that put data beyond their own reach, even when served with lawful process” (Hennessey 2017, p. 7). An investigator could obtain a search warrant, painstakingly adhere to search and seizure jurisprudence, and follow best practices throughout an investigation, but fail to obtain needed evidence, simply due to the presence of encryption, regardless of the severity of the crime or quantity of victims.

Key Points: Combatting Technology-Facilitated Child Abuse The preceding pages are filled with grim statistics and realities that ultimately fail to truly convey the scope and severity of the horror perpetrated on countless children, often with impunity. Many will be tempted to respond with either numbed indifference or paralyzed despair, but English writer, philosopher, and theologian G.K. Chesterton offered a third option:

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Can people hate the world “enough to change it, and yet love it enough to think it worth changing? Can he look up at its colossal good without once feeling acquiescence? Can he look up at its colossal evil without once feeling despair? Can he, in short, be at once not only a pessimist and an optimist, but a fanatical pessimist and a fanatical optimist? . . .it is the rational optimist who fails, the irrational optimist who succeeds. He is ready to smash the whole universe for the sake of itself.” (Chesterton 1908, pp. 130–131)

Meaningfully engaging with the overwhelming challenges discussed above requires ambitious, innovative, irrational optimism. On some issues, however, there are clear policy solutions. For example, the outcome of the encryption debate has tremendous implications for technology-facilitated child abuse. Although mandated access to encrypted content is politically controversial and strenuously opposed by many privacy advocates and others, the reality is that legal regimes which decline to mandate lawful, Fourth Amendment-restricted law enforcement access to encrypted content, at least in serious cases such as child sexual exploitation, permit perpetrator impunity, millions of undetected crimes committed against children, and the proliferation of unchecked offender networks. Attorney General William Barr has suggested that companies deploying encryption absent any mechanism for law enforcement access are essentially turning devices into “law-free zones,” preventing lawful access to needed data in criminal investigations, despite law enforcement compliance with the Fourth Amendment (Benner 2019). In a more proactive sense, states are laboratories of democracy (New State Ice Co. v. Liebmann, 1932), and learning from various state approaches is necessary to addressing technological threats to children. For example, some states struggle with criminal prosecution of offenders when law enforcement can establish that offenders viewed child sexual abuse material, but not that they downloaded the material, due to encryption or deletion of the data. West Virginia suggests a way forward for these states, penalizing any individual who “electronically accesses with intent to view” child sexual abuse material (W. Va. Code § 61-8C-3). Innovative technical tools that drastically increase the capacity and efficiency of law enforcement are critical. Project VIC is one organization supplying tools that have earned praise from law enforcement for enabling rapid identification of known child exploitation images via reference to datasets (Project VIC 2019). Artificial intelligence presents promising possibilities in innovating approaches to contraband detection and the identification of both perpetrators and previously unknown victims (Child Sexual Predators Have Nowhere to Hide 2019). At least one scholar has suggested the development of lawful hacking techniques to reduce the current comfort level of offenders, with the Network Investigative Technique (NIT) that successfully identified numerous perpetrators in Operation Playpen as a legal road map (Hennessey 2017, p. 12). Progress in combatting technology-facilitated child abuse must not come solely from new tools and technologies. Common sense and traditional investigative skills must also be applied to corroborate the online and in-person criminal activity of perpetrators. The phrase “he said, she said” will invariably be accurate if investigators only talk to “he” and “she.” All too often the phrase is merely an excuse for

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shoddy investigations, an indicator of insufficient training, or a consequence of unmanageable caseloads. Steps as simple as conducting timely interviews of all relevant third parties are often not taken. These investigative and prosecutorial shortcomings are painfully demonstrated by the fact that roughly 20% of sexual assault reports result in arrests and less than 1% of sexual assaults result in a criminal conviction (Anderson 2019). Survivors deserve much more robust investigative and corroborative efforts, as well as trauma-informed law enforcement approaches (Anderson 2019). Fortunately, digital evidence provides a wealth of corroborative opportunities for the thorough investigator. For example, exploring communications and social media activity with an intent to detect grooming activity or prior bad acts often proves rewarding in abuse investigations and prosecutions. Location data, if sought by the investigator and used by the prosecutor, is inherent in most modern devices and should eliminate false alibi defenses.

Summary and Conclusion Pertinent literature and practitioner insights alike establish the increasing scope and severity of child sexual abuse material, including the staggering amount of known images and videos reviewed by law enforcement and nonprofit entities annually, the strong trend toward younger victims, and the growing severity and violence of the depicted sexual exploitation itself. “Hands-on” grooming strategies have been adapted to the digital age, with perpetrators exploiting the advantages and disinhibitions of online interactions, ubiquity of Internet usage by children, and the corresponding minimal to nonexistent online supervision of many minors. Offenders target specific vulnerabilities through a variety of online platforms, deploying numerous manipulative tactics and, in many cases, directly voicing their sexual intent to minors. Survivor perspectives clearly demonstrate the devastating, ongoing impact of child sexual abuse material distribution. Emerging issues and trends include sextortion, live streaming, gaming platforms, the dark web and other anonymization methods, virtual reality, remote cloud storage, and encryption. To effectively combat these challenges and meaningfully disrupt technology-facilitated child abuse, law enforcement and stakeholders must embrace a combination of technical tools, traditional investigative tactics, and innovative policy solutions.

Cross-References ▶ Cyber Abuse in Romantic Relationships ▶ Examining Interpersonal Violence from a Trauma-Informed and Human Rights Perspective ▶ Human Trafficking and Intimate Partner Violence ▶ Missing and Exploited Youth ▶ Sibling Abuse of Other Children

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ia&utm_medium¼linkedin&utm_campaign¼magnet-whitepaper&utm_content¼whitepaper& fbclid¼IwAR0cRHDpmlibOXZQYyryen_yF8t0bzaG3rgDnovLD8eCi68P8cMtIYprDWU. Last accessed 3 Oct 2019. Riegel, D. L. (2004). Effects on boy-attracted pedosexual males of viewing boy erotica [Letter to the editor]. Archives of Sexual Behavior, 33, 321–323. Seto, M. (2013). Internet Sex Offenders. Washington, D.C.: American Psychological Association. Seto, M. C., Cantor, J. M., & Blanchard, R. (2006). Child pornography offenses are a valid diagnostic indicator of pedophilia. Journal of Abnormal Psychology, 115, 610–615. https:// doi.org/10.1037/0021-843X.115.3.610. Spraitz, J. D., & Bowen, K. N. (2019). Examination of a nascent taxonomy of priest sexual grooming. Sexual Abuse, 31, 707–728. https://doi.org/10.1177/1079063218809095. Talamo, L.. (2017, May 21). Lasting trauma for child victims. Shreveport Times. Shreveporttimes. com. https://www.shreveporttimes.com/story/news/investigations/2017/05/21/lasting-traumachild-victims/101486938/. Last accessed 3 Oct 2019. Thorn (Digital Defenders of Children). (2019). Child pornography and abuse statistics. www. wearethorn.org/child-pornography-and-abuse-statistics/ U.S. Department of Justice, Sex Offender Management Assessment and Planning Initiative (SOMAPI). (2017, March). https://www.smart.gov/SOMAPI/pdfs/SOMAPI_Full%20Report. pdf. Last accessed 3 Feb 2020. U.S. Department of Justice, The National Strategy for Child Exploitation Prevention and Interdiction. (2010, August). www.justice.gov/psc/docs/natstrategyreport.pdf. Last accessed 3 Oct 2019. U.S. Department of Justice, The National Strategy for Child Exploitation Prevention and Interdiction. (2016, April). www.justice.gov/psc/file/842411/download. Last accessed 3 Oct 2019. United Nations Office on Drugs and Crime. (2019, May). Online child sexual exploitation and abuse. https://www.unodc.org/e4j/en/cybercrime/module-12/key-issues/online-child-sexualexploitation-and-abuse.html. Last accessed 3 Oct 2019. Valentino-DeVries, J., & Dance, G. (2019, October 2). Facebook encryption eyed in fight against online child sex abuse. New York Times. https://www.nytimes.com/2019/10/02/technology/ encryption-online-child-sex-abuse.html. Last accessed 3 Oct 2019. Wakeman, J. (2017). Are teledildonics the future of long-distance sex? Retrieved from https://www. glamour.com/story/road-testing-teledildonics Webster S., et al. (2012, March). European online grooming project: Final report 51. European Commission Safer Internet Plus Programme. http://natcen.ac.uk/media/22514/european-onlinegrooming-projectfinalreport.pdf. Last accessed 1 Oct 2019.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rapport Building . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acute Examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Photo Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

This chapter discusses techniques and strategies for a thorough and atraumatic genital examination in the prepubertal child. Incorporating active participation by the child will also be discussed. Examination techniques that will be reviewed include supine position, knee-chest position, and labial separation and traction. Prepubertal exams do not typically require instrumentation to observe a complete view of the hymen, so it is important to master these techniques. Documentation of the genital exam by still photography and video recording will also be discussed.

This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. N. Ayson (*) · S. Starling University of California San Diego School of Medicine/Rady Children’s Hospital San Diego, San Diego, CA, USA e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_242

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Keywords

Medical history · Rapport · Female genitalia · Male genitalia · Labial separation · Labial traction · Knee chest position · Acute examination

Introduction The medical examination is one component of a complete evaluation for sexual abuse. There are many reasons that a genital exam should be performed when there is suspected sexual abuse in a prepubertal child. During the medical exam, injuries may be identified, sexually transmitted infections (STIs) can be diagnosed and treated, and forensic evidence can be collected (if the last known event is recent enough to fall into the timeframe for evidence collection guidelines for the jurisdiction). The exam also can be therapeutic for the child and family. Children often have a misunderstanding about what findings may be present on or in their bodies or may feel that their bodies have been permanently and visibly changed in some way by the alleged abuse. The medical exam is often the first step in the healing process. It provides counseling and reassurance to the child and caregiver after abusive events. It is also a time to address any mental health needs related to the trauma and provide referrals to trauma focused mental health services (Jenny et al. 2013).

Medical History Prior to the examination, obtain past medical history from the caregiver and from the child, if the child is mature enough to provide history. Review any previous or current medical conditions and/or surgeries, as these may affect how the examination is performed and the subsequent assessment of any findings. Inquire about any recent genital or anal injuries (Finkel 2009). Jurisdictional practices will guide the interview process of a child. The child may be interviewed about details of the abuse by law enforcement, social workers, forensic interviewers, and/or the medical team. It is important to limit the number of interviews conducted with a child in order to reduce the child’s stress, enhance his/ her cooperation, and potentially reduce interference in an investigation. Additional details regarding the allegations may be gathered from the caregiver. Pertinent information that should be gathered includes timing of the most recent incident or last possible contact with the perpetrator, types of acts alleged to have occurred, and any known physical findings possibly related to the alleged abuse. The medical provider may need to obtain further details from the child regarding the sexual abuse allegations, as guided by jurisdictional practices. It is preferable for the medical provider to interview the child alone. The medical provider should have training in forensically sound medical history gathering techniques. The provider should ask open-ended and non-leading questions to gather information that may help guide certain elements of the examination, such as testing for sexually

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transmitted infections and forensic evidence collection. Forensic evidence collection is dependent on the guidelines of each jurisdiction, and this will be discussed later in the chapter. Questions that should be asked include the types of acts alleged to have occurred and whether the child has had any symptoms after the alleged incident. One study of girls who had disclosed sexual abuse found that 53% endorsed genital pain, 37% endorsed dysuria (painful urination), and 11% had genital bleeding temporally related to inappropriate sexual contact (DeLago et al. 2008). It is important to inquire about these symptoms from the child or their caregiver.

Rapport Building Prior to the exam, rapport must be established with the child and family. Clear introductions of each staff member and an explanation of their roles during the exam are beneficial for the child and caregiver. Age-appropriate language should be used during all interactions. Children may have questions about the exam that can be addressed at this introductory session. Caregivers may have their own concerns and questions about the appointment and exam. Answering these questions beforehand and providing explanations appropriate to their level of health literacy will aid in a successful visit. Explaining the role of photography or videography can help to ease any anxiety regarding documentation of the exam. It is important that children and parents understand that these images are medically necessary to document findings and may reduce the need for further re-examination in the future. Having a younger child touch or explore the recording equipment can also put them at ease. Any medical equipment, such as swabs, used for evidence collection during the exam can be introduced beforehand. Providing the patient with as much decision-making responsibility as possible will improve participation by the child. For young children, allowing them reasonable choices gives them a sense of pride and control over what happens with their bodies. Rapport can be easily built in a matter of minutes by conversing about nonthreatening topics such as school, toys, or pets. Children of varying ages have different fears and worries. If the child understands that the medical staff is comfortable in discussing a difficult topic such as sexual abuse, then this will be encouraging to the child. Patients often benefit from the assurance that the provider is comfortable with other difficult topics such as consensual sexual activity, STIs, and substance use. Children also should be given a choice as to which, if any, caregiver(s) are present during the genital exam. Once a caregiver is chosen, the child can be given a further choice of where they would like their caregiver to be positioned during the exam. For example, asking the child if they would like their caregiver to stand and hold their hand during the exam or sit in a chair nearby are both acceptable options for the child and caregiver. In addition to the caregiver, the medical provider may also have an additional staff member chaperone the exam. This should be explained to the child and parent. This also is a time where the caregivers should be reminded that their primary focus is to support the child and to be a calming presence for the child. If

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they do not think they can accomplish these tasks, then alternative plans should be made.

Anatomy The American Professional Society on the Abuse of Children (APSAC) provides written definitions of the anatomical structures of the anogenital region. The female and male genitalia are defined here as described by APSAC (Conte et al. 2018) (Fig. 1).

Female Genital Anatomy The vulva is a term that encompasses all the external genital structures of the female. The mons pubis is the fatty tissue area over the pubic bones. The labia majora are longitudinal folds of tissue that protect the labia minora and inner structures. The labia minora are folds of tissue that form near the clitoris. The clitoris is a cylindrical structure that is located superior to the urethra and is analogous to the penis. The urethral opening is located inferior to the clitoris and between the labia minora. The vaginal vestibule is a space formed by the labia minora, clitoris, hymen, and posterior fourchette/commissure, which is represented in the image as the space within the dotted oval. The posterior fourchette/commissure is the point at which the labia minora meet posteriorly. The fossa navicularis is a concave space between the posterior attachment of the hymen and the posterior fourchette. Male Genital Anatomy The male genitalia includes the penis, scrotum, and testes (Fig. 2). The penis is a cylindrical structure composed of the glans; at the tip, the opening of the urethra is found. The base of the glans is referred to as the corona. The dorsal surface of the

Fig. 1 External structures of the female

Labia majora

Clitoral hood

Labia minora Urethra

Hymenal opening

Hymen

Fossa navicularis Posterior fourchette

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Fig. 2 External structures of the male, circumcised

Shaft of penis Corona of glans Glans of penis Urethra

Scrotum

penis is anterior to the body, and the ventral surface of the penis contacts the scrotum. The scrotum is a sac-like structure which contains the testes and epididymis. The testes are oval-shaped organs inside the scrotum that contain hormone and spermproducing cells.

Female Pubertal Development Pubertal development has been categorized into sexual maturity ratings by describing the appearance of a female’s breasts and pubic hair, and a male’s genital size and pubic hair (Witchel and Finegold 2002). A prepubertal female is considered stage one and lacks any breast development and pubic hair (Fig. 3). The average American female child starts puberty around ages 8–9 years. As the production of estrogen increases during puberty, breast tissue enlarges, and the papillae and areolae grow and extend above the contour of the breast. Estrogen also stimulates lengthening of the labia and thickening of the hymen. Androgen hormones influence the growth of axillary and pubic hair. In stage 2, darker pigmented hair develops on the pubic region, and this hair becomes coarser, thicker, and more abundant, with hair extending onto the medial surface of the thighs in stage 5.

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Fig. 3 Female sexual maturity ratings. (Image by Catherine Cichon, MD)

Male Pubertal Development A male in stage one is prepubertal, without any sexual development of his penis, scrotum, and testes (Fig. 4). American males typically start puberty later than females, around 9–10 years old. Testosterone production causes growth of the penis, scrotum, and testes. The penis grows in length and circumference through the stages. The scrotum enlarges and scrotal skin becomes more textured and hyperpigmented. The volume of the testes enlarges as a male progresses through puberty, as indicated in the figure. Androgen hormones in males produce hair growth on the face, body, axilla, and pubic regions. Pubic hair development follows a similar pattern as described in females.

Medical Exam Performing a general physical exam prior to the genital exam can allow the child and medical provider to further build rapport in addition to gathering medically relevant

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Fig. 4 Male sexual maturity ratings. (Image by Catherine Cichon, MD)

information. Most children have already experienced general physical exams during their well child checks with their primary care provider, so this will feel familiar to them. Have the child change into a medical gown to allow a complete examination. It is important to keep unexamined areas covered with a blanket or sheet to respect the

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child’s privacy. If the child does not want to change into a gown, disrobing each body area one at a time can also offer some privacy and comfort to the child. The routine physical exam provides for inspection of the child’s body for physical abuse injuries such as bruises, strangulation injuries, bite marks, or suction injuries. Videocolposcopy and/or photo documentation of any concerning injuries should be recorded. The medical record should include written documentation describing the character and location of the findings. If there are any findings, the child should be asked how the injury occurred, and these statements should also be included in the written documentation. Many children do not have routine medical care, and screening them for general pediatric illness can be of great benefit to them. Medical diagnoses such as otitis media or other acute illnesses can be diagnosed during the examination. Other medical concerns such as heart murmurs or undiagnosed congenital anomalies may be found, especially in children with inconsistent attendance at primary care visits.

Female Genital Exam The female prepubertal genital exam starts in the supine position with the child lying on her back with her hips abducted and the soles of her feet touching, also known as the frog leg or butterfly position (Fig. 5). If the girls are taller, the lithotomy position with table stirrups may be used. Some children will be more cooperative being examined while lying in the lap of their caregiver. The caregiver can also sit on the examiner’s table with the child seated between their legs if that increases the child’s ability to cooperate. It will also be useful to set up any testing material such as swabs or saline on a nearby medical stand. Start inspection of the external genitalia in a systematic way, such as superior to inferior or lateral to medial. Sexual maturity staging may be done during inspection. Next is examination of the medial structures of the female genitalia. This requires Fig. 5 A prepubertal child in the supine frog leg position. (Image by Catherine Cichon, MD)

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separation of the labia majora. The examiner should grasp the lower half of the labia majora between the thumb and index finger. Separation of the labia majora requires application of gentle force laterally on both sides to reveal the introitus, clitoral hood, periurethral tissues, and hymen (Fig. 6). Afterward, labial traction can be performed to reveal the posterior structures such as the fossa navicularis and posterior fourchette (Fig. 7). Labial traction requires gentle pulling of the labia majora anteriorly toward the examiner. Excessive traction or separation can cause iatrogenic injuries to the posterior fourchette. Visualization of the hymenal tissue is improved through traction from the horizontal forces applied. If the hymen is not fully visualized with these maneuvers during supine positioning, normal saline irrigation of the hymen can be Fig. 6 Labial separation. Arrows indicate the lateral motion of the examiner’s hands. (Image by Catherine Cichon, MD)

Fig. 7 Labial traction. Arrows indicate the pulling of the labia majora towards the examiner. (Image by Catherine Cichon, MD)

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performed. Gently drop saline onto the hymen to reduce the tension of the tissue which may be folded on itself. Afterward, repeat separation and traction to visualize the hymen. Grasping the labia in various positions may also aid visualization. Much of the anogenital examination is focused on proper visualization of the hymen and surrounding anatomical structures. When describing the anatomy and any abnormality of the hymen, it is most practical to describe location using a clock face as a reference (Fig. 8). For instance, with the patient in a supine position, 12 o’clock represents the ventral or anterior midline area; the urethra is at 12 o’clock with respect to the hymen. The dorsal or posterior midline area where the posterior fourchette is located is at 6 o’clock. Another important exam position that can be utilized in female exams is the prone knee-chest position (Fig. 9). If there are any abnormalities or concerns noted during the supine examination, then the prone knee-chest position should be performed for further evaluation and confirmation of the findings. This position requires more active participation by the patient and caregiver. Showing a drawing or cartoon of this position can be useful in helping the patient understand the position you would like them to use. Using a photo of a cat stretching can also demonstrate the position. It is important for the child’s chest and knees to contact the table while her buttocks are directly over her knees, with the stomach slumped toward the examination table. Having her knees shoulder width apart will also provide the patient stability during this portion of the exam. This position allows gravity to assist in visualizing the posterior portion of the hymen, which sometimes

Fig. 8 Hymen clock face

12 9

3 6

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Fig. 9 Prone knee-chest position. (Image by Catherine Cichon, MD)

Fig. 10 Prone knee-chest position with arrows indicating upward motion of examiner’s hands. (Image by Catherine Cichon, MD)

cannot be visualized with a child in the supine position. The examiner’s hands should lift the buttocks upward, raising the tissue superiorly without lateral traction, to reveal the vestibule and hymen (Fig. 10). Normal saline may also be used to aid visualization while the child is in this position. Prepubertal genital exams do not typically require introduction of instruments into the vagina. Prepubertal children have atrophic vaginal mucosa, and the hymen is very sensitive to touch due to the child’s low estrogen levels. If there is concern for a vaginal infection, a urine specimen may be collected or a swab may collect discharge external to the hymen. Another option includes gentle irrigation of the vestibule with water while holding a swab below the posterior fourchette to catch the drainage. If there is a need to explore the vaginal canal or hymen (such as unexplained vaginal bleeding), then referral to pediatric gynecology is needed to assist with a sedated examination.

Male Genital Exam The male genital exam can be done in the supine, seated, or standing position. Inspect the penis, scrotum, and testes. Nonretractile foreskin should not be retracted. In general the foreskin does not become fully retractile until the age of 6 years. The child can assist the medical provider by exposing the ventral surface of the penis and

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scrotum during inspection. If the penis is uncircumcised and the child has a retractile foreskin, then ask the child to retract the foreskin as they would during urination and inspect for any injuries. The examination findings should be discussed with each child and the supportive caregiver. Some children may even ask to see their photos if the examination is not projected for them at the time. This is an opportunity to educate them about safety and health.

Anal Exam Visualization of the anus can be done easily in the supine knee-chest position, often referred to as the “cannonball” position (related to a common swimming pool jump) for males and females (Fig. 11). The child can assist with the exam by holding his/her knees against the chest. A caregiver may also take part in this by helping the child hold his/her knees. The prone and lateral decubitus positions may also be used, but are more difficult to photograph, and often are more uncomfortable for the child. Choose a position that provides the most comfort for the patient, which can aid cooperation of the patient, and enhance visualization. Separate the buttocks to visualize the anal and perianal areas. Apply gentle lateral buttock traction to separate the anal rugae so that the anal orifice can be inspected. Separate all the rugae circumferentially in a systematic way starting at 12 o’clock to ensure that no area is missed. During the exam, the child’s anus may dilate, and the pectinate/dentate line and rectum may be easily visualized.

Acute Examinations If the timing of the assault is less than 72–120 hours prior to the evaluation, forensic evidence may be collected during this acute examination of the child (Anderst 2011). Fig. 11 Supine knee-chest or “cannonball” position for the anal examination. (Image by Catherine Cichon, MD)

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This decision is usually made in conjunction with law enforcement and in accordance with forensic guidelines for the state/jurisdiction. The child should be assessed for any potentially life-threatening injuries prior to undergoing an acute/emergent evaluation for sexual assault. Medical providers should familiarize themselves with the existing forensic protocols in their community regarding evidence collection and timing. If more than 120 hours have passed since the alleged incident occurred, an acute/emergent exam is not typically necessary unless there are symptoms present which may indicate an injury or infection. For children who present for care outside of the 120 hours timeframe, an exam may be scheduled at a later time and performed in a clinic setting, such as a child advocacy center or medical clinic. Further discussion can be found in the “Forensic Analysis of Sexual Abuse Cases” chapter of this textbook.

Photo Documentation Photo and/or video documentation is considered standard of care when evaluating a child for sexual abuse. Photos are used to document injuries, obtain second opinions, and provide for peer review (Adams et al. 2018). There are various types of photography equipment that may be used. The colposcope was the primary instrument initially used in the field of child sexual abuse (Fig. 12). It can magnify up to 20x and has a built in light source. A camera and flash are also attached for photo documentation. The instrument is attached to an arm or wheels to allow mobility during the exam. It is usually situated close to the patient but never physically Fig. 12 Anal anatomy

Anal orifice

Anal rugae Pectinate line

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touches any part of the patient’s body. More recently, digital single lens reflex (DSLR) cameras with video recording capabilities are being used due to their technological advances, lower cost, and easy accessibility, among other reasons. Video recording allows the entire examination to be documented and has the ability to demonstrate the dynamic changes of the genital and anal tissue. One study showed increased agreement of diagnoses by examiners reviewing video documentation versus still images (Killough et al. 2016). Depending on the equipment and computer programs used, it is possible to extract still images from video recordings. Each clinic should have policies regarding storage of photos and videos to ensure this sensitive information is secured. In addition to photo documentation, diagram drawings with labels and descriptions can be used (Figs. 13 and 14). Before beginning the examination, ensure that the recording equipment is within reach of the examiner. Photographing patient identification should be done first. The patient’s name, date of exam, and the examiner’s name/initials should be clearly visible. Ensure that the expected position of the child will provide adequate focus through the recording equipment. Photographing the patient initially at medium range provides anatomical orientation. Then a magnified image of any findings or injuries can be taken. Review the photos or videos before having the child dress to ensure quality images were obtained during the exam and to avoid repeated examinations in the future. Some children express a desire to watch their examination. If the exam room can be set up to project the recording in real time, this will enable the Fig. 13 Colposcope

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Fig. 14 Video camera attached to mobile tripod

child to see their examination with minimal difficulty. Watching the examination provides a sense of participation and control and may also demystify the examination for the child and the caregiver.

Key Points • Physical examination is an important part of the evaluation for sexual abuse and serves medical, forensic, and therapeutic purposes. • Proper history collection for sexual abuse concerns may be done by a variety of professionals, dependent on jurisdictional practices. • Familiarity with the female and male genitalia (including anal anatomy) is necessary for a proper evaluation. • Multiple exam techniques must be mastered to complete a thorough physical evaluation. • Photo documentation is an essential component to a complete examination.

Summary and Conclusion The prepubertal medical evaluation is essential to the diagnosis and treatment of sexual abuse. It is also a starting place for the healing process. The exam allows for evaluation for infections or other health issues, and subsequent referral for mental

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health concerns. All medical providers and community partners should be aware of the importance and utility of this exam.

Cross-References ▶ Normal Examination Findings and Variants

References Adams, J. A., Farst, K. J., & Kellogg, N. D. (2018). Interpretation of medical findings in suspected child sexual abuse: An update for 2018. Journal of Pediatric and Adolescent Gynecology, 31(3), 225–231. https://doi.org/10.1016/j.jpag.2017.12.011. Anderst, J. (2011). The forensic evidence kit. In C. Jenny (Ed.), Child abuse and neglect: Diagnosis, treatment, and evidence (1st ed., pp. 106–111). St. Louis: Saunders/Elsevier. Conte, J. R., Klika, J. B., & American Professional Society on the Abuse of Children. (2018). The APSAC handbook on child maltreatment (4th ed.). Los Angeles: SAGE. DeLago, C., Deblinger, E., Schroeder, C., & Finkel, M. A. (2008). Girls who disclose sexual abuse: Urogenital symptoms and signs after genital contact. Pediatrics, 122(2), e281–e286. https://doi. org/10.1542/peds.2008-0450. Finkel, M. (2009). Physical examination. In M. A. Finkel & A. P. Giardino (Eds.), Medical evaluation of child sexual abuse: A practical guide (3rd ed., pp. 19–52). Elk Grove Village: American Academy of Pediatrics. Jenny, C., Crawford-Jakubiak, J. E., & American Academy of Pediatrics and Committee on Child Abuse and Neglect. (2013). The evaluation of children in the primary care setting when sexual abuse is suspected. Pediatrics, 132(2), e558–e567. https://doi.org/10.1542/peds.2013-1741. Killough, E., Spector, L., Moffatt, M., Wiebe, J., Nielsen-Parker, M., & Anderst, J. (2016). Diagnostic agreement when comparing still and video imaging for the medical evaluation of child sexual abuse. Child Abuse & Neglect, 52, 102–109. https://doi.org/10.1016/j. chiabu.2015.12.007. Witchel, S. F., & Finegold, D. N. (2002). Endocrinology. In B. J. Zitelli & H. W. Davis (Eds.), Atlas of pediatric physical diagnosis (4th ed., pp. 330–333). St. Louis: Mosby.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Newborn Hymen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hymenal Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Additional Female Genital Anatomical Variants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Normal Anal Variants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Misconceptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

992 992 992 997 1000 1002 1003 1004 1004 1004

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This section reviews normal genital and anal anatomy of prepubertal children. It will describe the physical changes of genitalia that occur as a child moves toward puberty, with particular attention to hymen morphology. Normal variants that will be discussed include notches, clefts, ridges, bands, and midline anatomic features, among others. It is important to master these concepts as many prepubertal exams for sexual abuse may have one of these normal variants. Keywords

Annular hymen · Crescentic hymen · Mounds · Notch · Cleft · Periurethral bands · Diastasis ani · Pectinate line This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. N. Ayson (*) · S. Starling University of California San Diego School of Medicine/Rady Children’s Hospital San Diego, San Diego, CA, USA e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_243

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Introduction In the majority of prepubertal genital examinations, there are no definitive physical findings of sexual abuse. The study by Berenson et al. in 2000 showed that fewer than 5% of abused children ages 3–8 years old have findings suspicious for or diagnostic of abuse. A child’s disclosure is therefore the most important evidence for the diagnosis of child sexual abuse. The Genital Examination Techniques chapter described specialized examination techniques that are required for the evaluation of suspected child sexual abuse. Understanding normal findings and variants is critical to ensuring that injury is not overcalled.

Newborn Hymen The newborn genital exam usually reveals a thickened and redundant hymen along with an enlarged clitoris and prominent labia majora. Estrogenization from maternal hormones during pregnancy causes this appearance of the newborn genitalia. This estrogen effect has been documented to persist up to the first 2 years of life. As maternal hormones are metabolized and the infant returns to a lower estrogen state, the hymen typically evolves into a thin translucent membrane of varying configurations during the prepubertal stage (McCann et al. 1990).

Hymenal Findings There are multiple normal configurations of the hymen. Annular hymens (Fig. 1) have a complete ring of tissue surrounding the vaginal orifice. A crescentic hymen lacks tissue anteriorly, often between the 11 and 1 o’clock positions (Fig. 2). Multiple studies of prepubertal girls have shown that a crescentic hymen is more common than an annular hymen after the newborn stage (McCann et al. 1990; Myhre et al. 2003). An imperforate hymen, or hymen with no opening, is a rare finding (Figs. 3 and 4). This requires surgical creation of an opening prior to the onset of menses. When this hymenal variant is seen, a referral to a gynecologist (preferably a specialist in pediatric/adolescent gynecology) is warranted. Similar to an imperforate hymen, a microperforate hymen (hymen with one or more small perforations) will cause obstruction of menstrual flow at puberty, and a child with this hymenal configuration should also be referred to a gynecologist, preferably with pediatric/adolescent experience. A redundant hymen, sometimes referred to as a fimbriated hymen, has multiple folds of tissue and is best evaluated in multiple examination positions, such as supine and prone knee chest (Fig. 5). A septate hymen is described as a hymenal opening with a band of tissue bisecting the opening (Fig. 6). This should be closely evaluated to ensure that the hymenal septum is not actually a vaginal septum, which may lead to complications with menses, fertility, and childbirth later in adulthood. Ultrasound may be needed to clarify this finding. A cribriform hymen has multiple hymenal openings.

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Fig. 1 Annular hymen – While the examiner applies traction to the labia majora, the hymen is visualized with a complete ring of tissue surrounding the vaginal opening. The urethra is seen anterior to the vagina. Periurethral bands are also present. Vaginal columns can be seen at 6, 9, and 12 o’clock

Fig. 2 Crescentic hymen – This prepubertal child has a crescentic hymen because there is no tissue between the 11 and 1 o’clock positions of the hymen. There is a slight hymenal mound at 9 o’clock

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994 Fig. 3 Imperforate hymen – An imperforate hymen is visualized in the supine position

Fig. 4 The vaginal opening is not present in the prone position. This confirms the finding of an imperforate hymen

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Fig. 5 Redundant hymen – The examiner is using traction technique to observe a redundant hymen. The hymenal opening to the vagina is not visualized in this photo

Fig. 6 Septate hymen – A band of tissue intersects the hymenal opening, producing two hymenal openings

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Fig. 7 Hymenal mounds

Hymenal bumps, mounds, and tags are all terms that are used to describe a projection of tissue along the edge of the hymen (McCann et al. 1990; Fig. 7). These can be found in any position along the hymenal rim. A hymenal notch or cleft appears as an indentation on the edge of the hymen in any position. Clefts at or above the 3 and 9 o’clock positions are frequently seen and considered normal variants, as documented in the 1992 Berenson study. Due to the natural variation seen along the anterior hymenal rim, any indentation or absence of tissue located between 3 and 9 o’clock should not be considered to be the sequelae of trauma unless an acute injury was previously documented in that location. Shallow notches or clefts (which do not extend to the base) in any position on the hymen are also considered normal variants. Deep notches along the posterior rim do not currently have any expert consensus as to their significance in regard to prior trauma and are therefore considered “nonspecific” (Adams et al. 2018). This annular hymen has mounds located at 4 and 7 o’clock. Note the erythema of the hymen and vestibular walls, which are also common prepubertal findings. Prepubertal hymens frequently have prominent superficial blood vessels that give the appearance of erythema to the naked eye. Under magnification these vessels can be visualized in multiple exam positions. They may be described as lacy in appearance. Sometimes these may be mistaken for petechiae or bruises, but follow-up examinations will show that the findings do not resolve as would be expected with injury.

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Additional Female Genital Anatomical Variants Vaginal ridges and columns are common anatomic findings (Fig. 8). These are mucosal ridges located on the walls of the vagina and are sometimes mistaken for scarring. Intravaginal columns may extend to the hymen and form a hymenal mound where the ridge meets the hymen (McCann et al. 1990). These findings often are best seen in the prone knee chest position but can be seen easily in supine position in a relaxed child. Vestibular mucosal erythema is a very common finding in prepubertal children due to the high vascularity of the genital tissues (Fig. 9). Redness is generally the result of factors unrelated to abuse. Very pronounced redness may be related to irritation and inflammation from poor hygiene resulting in vulvovaginitis. Other potential etiologies of vulvovaginitis include infections like group A beta-hemolytic streptococcus, Haemophilus influenzae, or Shigella (Sugar and Graham 2006). Additional lab testing is recommended for these diagnoses. Some children may have hyperpigmentation of their labia minora, scrotum, and/or perianal tissue (Fig. 10). This is most commonly seen in African American children or other ethnicities with increased pigmentation. It is considered a normal finding. This prepubertal child has vestibular erythema that is frequently related to poor hygiene with toileting practices. There is hymenal erythema at 2 and 7 o’clock due to focal increased vascularity. A Hispanic 2-month-old female with hyperpigmentation of her labia minora and surrounding tissues.

Fig. 8 Vaginal column and ridges – An intravaginal column is prominent along the posterior vaginal wall and extends to the edge of the hymen ending in a mound at 6 o’clock. Multiple transverse vaginal ridges extend on either side of the column

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Fig. 9 Vestibular and hymenal erythema – This prepubertal child has vestibular erythema that is frequently related to poor hygiene with toileting practices. There is hymenal erythema at 2 and 7 o’clock due to focal increased vascularity

Fig. 10 Hyperpigmented labia minora - A Hispanic 2-month-old female with hyperpigmentation of her labia minora and surrounding tissues

Periurethral and perihymenal bands are fibrous bands of tissue that serve as supportive structures and may form a false pocket on either side of the urethra or hymen (Fig. 11). They are very common and may be more easily seen during labial traction (McCann et al. 1990). Urethral dilation is a finding that can be observed when traction is applied during the female genital exam. This finding does not have any significance with respect to sexual abuse.

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Fig. 11 Periurethral bands

Fig. 12 Anterior labial adhesions – Separation of the labia majora reveals an annular hymen, but the urethral opening is obstructed by an anterior labial adhesion (arrow)

Bilateral periurethral bands are present anterior to the hymen. Prominent perihymenal erythema is present, which is a normal finding. Labial adhesions (also called labial agglutination) are a term that describes a fusion of the labia majora or minora in the midline, either posteriorly or anteriorly, to form a membrane (Fig. 12). The minora may also fuse laterally to the majora. These findings are most common in girls less than 2 years old but can occur until early

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Fig. 13 Linea vestibularis – The arrow indicates the location of linea vestibularis

adolescence. When estrogen levels increase around the time of puberty, agglutination tends to resolve. Posterior adhesions may obstruct the view of the posterior hymen in some or all examination positions. An anterior adhesion may obstruct visualization of the urethra. If urine flow is blocked by the adhesion, this may lead to vulvovaginitis or urinary tract infections. The adhesions can be monitored over time or, if severe, can be treated using topical estrogen. Very thick or extensive adhesions may need urologic intervention if there is obstruction of urinary flow. The linea vestibularis is a normal variant described as an avascular area of the posterior vestibule or perineal body which appears pale and is often confused with scarring (Kellogg and Parra 1991; Fig. 13). Excessive traction during the exam can give a false impression of blanching, so this finding should be verified in multiple positions. The median raphe is a midline perineal hyperpigmentation (sometimes with a palpable ridge) that represents the site of fusion between the two sides of the perineum in the prenatal period (Fig. 14).

Normal Anal Variants Diastasis ani is a pale, smooth area of the external anal sphincter most commonly located at the 6 and 12 o’clock positions (Fig. 15). It is surrounded by the normal rugae of the anus. A perianal skin tag is an area of excess skin usually found in the midline positions of the anal opening (Fig. 16). The tag is usually soft, flesh colored and may be related to constipation (McCann et al. 1989).

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Fig. 14 Median raphe – This is seen as linear hyperpigmentation on this child’s scrotum extending toward the perineum

Fig. 15 Diastasis ani and perianal venous congestion – Diastasis ani is seen at the 6 o’clock position. The bluepurple engorged areas surrounding the diastasis represent perianal venous congestion

Perianal venous congestion is discoloration around the anus that becomes more prominent typically during the examination in the supine position. This can be distinguished from bruising because the discoloration of venous congestion resolves with changes in position. If the anal sphincter is relaxed, it dilates, and can cause a

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Fig. 16 Perianal skin tag – The perianal skin tag is seen at 12 o’clock with the patient in the supine position

distinct margin of prominent erythema to be seen within the anus. This area is the pectinate line, which can sometimes be confused with an anal injury (Fig. 17). Diastasis ani is seen at the 6 o’clock position. The blue-purple engorged areas surrounding the diastasis represent perianal venous congestion. The pectinate line is a distinct line of demarcation between the keratinized skin of the anal canal and the anal mucosa.

Misconceptions There are many misconceptions regarding the hymen. One myth is that a female child can be born without one. Two observational studies, totaling more than 25,000 female newborn examinations, have disproven this, showing that all genetic female children have a hymen present (Jenny et al. 1987; Mor and Merlob 1988). Many laypeople are under the impression that the hymen is a solid band of tissue that must be ruptured during the first episode of intercourse. Parents and even patients may ask if the hymen is intact or broken, or if the child is “still a virgin,”

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Fig. 17 Pectinate line

after a sexual encounter has occurred. Unless the child has an imperforate hymen, there is always an opening in the hymenal membrane. Measurements of the size of the hymenal opening have been analyzed in previous studies, which have not provided consistent evidence in support of vaginal penetration (Berenson et al. 2002). Factors which affect the size of the hymenal opening include examination position and relaxation of the child; these factors do not have a relationship with the occurrence of sexual abuse. There is no scientific evidence to support the practice of measuring the hymenal orifice. This concept should be explained to caregivers and medical providers when they share a concern that the hole looks too big.

Key Points • Most prepubertal exams for sexual abuse do not have any physical findings. • There are a variety of hymen configurations and variants that are considered normal. • There are also multiple normal variants seen on an anal examination. • Our society has misconceptions regarding the exam findings after alleged sexual abuse, and these previously held beliefs have scientifically been proven to be false.

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Summary and Conclusion The medical exam is an essential component of the evaluation of children who may have been sexuall y abused. The majority of genital and anal exams of prepubertal children will be normal. Overdiagnosing abuse secondary to the misinterpretation of a normal finding should be avoided. Accurate diagnosis of these normal variants is important for medical care of the child as well as the legal implications of diagnosed child sexual abuse.

Cross-References ▶ Sexual Abuse of Children

References Adams, J. A., Farst, K. J., & Kellogg, N. D. (2018). Interpretation of medical findings in suspected child sexual abuse: An update for 2018. Journal of Pediatric and Adolescent Gynecology, 31(3), 225–231. https://doi.org/10.1016/j.jpag.2017.12.011. Berenson, A. B., Chacko, M. R., Wiemann, C. M., Mishaw, C. O., Friedrich, W. N., & Grady, J. J. (2002). Use of hymenal measurements in the diagnosis of previous penetration. Pediatrics, 109(2), 228–235. Jenny, C., Kuhns, M. L., & Arakawa, F. (1987). Hymens in newborn female infants. Pediatrics, 80(3), 399–400. Kellogg, N. D., & Parra, J. M. (1991). Linea vestibularis: A previously undescribed normal genital structure in female neonates. Pediatrics, 87(6), 926–929. McCann, J., Voris, J., Simon, M., & Wells, R. (1989). Perianal findings in prepubertal children selected for nonabuse: A descriptive study. Child Abuse & Neglect, 13(2), 179–193. https://doi. org/10.1016/0145-2134(89)90005-7. McCann, J., Wells, R., Simon, M., & Voris, J. (1990). Genital findings in prepubertal girls selected for nonabuse: A descriptive study. Pediatrics, 86(3), 428–439. Mor, N., & Merlob, P. (1988). Congenital absence of the hymen only a rumor? Pediatrics, 82(4), 679–680. Myhre, A. K., Berntzen, K., & Bratlid, D. (2003). Genital anatomy in non-abused preschool girls. Acta Paediatrica, 92(12), 1453–1462. Sugar, N. F., & Graham, E. A. (2006). Common gynecologic problems in prepubertal girls. Pediatrics in Review, 27(6), 213–223. https://doi.org/10.1542/pir.27-6-213.

Acute Sexual Assault Evaluation of the Prepubertal Child

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Amber L. Shipman, Dawn Scaff, Cassandra Elverum, and Michelle Clayton

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Account of Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Additional History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Physical Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Anogenital Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Female Anogenital Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Male Anogenital Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Forensic Evidence Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Steps for Evidence Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Photodocumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alternative Light Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Testing for Sexually Transmitted Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Drug-Facilitated Sexual Assault . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Findings and Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Forensic Evidence Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Understanding DNA Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Spermatozoa and Seminal Fluid Markers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trace Evidence Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clothing Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Forensic Evidence in Prepubertal Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Use of Physical and Forensic Evidence in Criminal Proceedings . . . . . . . . . . . . . . . . . . . . Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1006 1007 1007 1009 1010 1011 1011 1012 1012 1014 1019 1020 1021 1022 1027 1029 1029 1033 1034 1034 1034 1035 1036

This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. A. L. Shipman · M. Clayton (*) Eastern Virginia Medical School/Children’s Hospital of The King’s Daughters, Norfolk, VA, USA e-mail: [email protected]; [email protected] D. Scaff · C. Elverum Children’s Hospital of The King’s Daughters, Norfolk, VA, USA e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_121

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HIV Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sexually Transmitted Infection Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Treatment of Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Addressing Physical and Mental Health Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discharge Planning and Follow-Up Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

When a child makes a disclosure of acute sexual assault, the need for a timely evaluation becomes paramount. In this situation, the responsibility of the examiner becomes twofold: (1) ensuring appropriate medical care is provided for the child and (2) collection of forensic evidence to assist with investigation of the child’s disclosure. The primary focus of the examiner should be to perform a trauma-informed, victim-centered evaluation of the child, which is developmentally appropriate to individual child’s needs. The examiner should be able to obtain any necessary history, perform a thorough physical examination, determine what laboratory evaluation may be indicated, and address any medical or psychological needs which may be identified. This chapter will focus on the medical and forensic components of the acute sexual assault evaluation of prepubertal children, including the collection of historical, physical, and forensic evidence; laboratory evaluation; interpretation of findings; and medical management considerations for this patient population. Keywords

Acute sexual assault examination · Pediatric · Prepubertal · Forensic examination · Evidence collection · Anogenital · Injuries · DNA analysis · Alternative light sources

Introduction When a recent disclosure of sexual assault has been made, a forensic medical examination of the prepubertal child is recommended. The forensic medical examination serves two purposes; (1) ensuring appropriate medical care is provided for the child and (2) collection of forensic evidence to assist with investigation of the child’s disclosure. Every effort should be made to ensure that the child is not retraumatized by the examination and that the examiner explains the examination procedure and findings to the child and the caregivers(s). This chapter focuses on the medical and forensic components of the acute sexual assault evaluation of prepubertal children. An acute sexual assault evaluation involves the examination and care of a child who has been recently assaulted. This typically involves an assault occurring within the preceding hours or days; however, the exact timeframe varies by jurisdiction. This chapter discusses the medical history

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of the child, account of the events that were disclosed, important aspects of the physical examination, detailed steps for collection of evidence (including photodocumentation and alternative light sources), interpretation of examination and laboratory findings, testing and treatment of sexually transmitted infections (STIs), the medical management, and appropriate follow-up of prepubertal pediatric patients.

The History As in any examination, when providing an acute sexual assault examination for the prepubertal child, the first step is obtaining a history. The history is obtained through a variety of information sources, including but not limited to caregivers, police, child protective services, and/or the child themselves. In general, the information should be obtained from all other sources before obtaining information from the prepubertal child. Sufficient information should be obtained in order to ensure that an appropriate examination is completed and that all of the child’s medical needs are met. Whenever possible, the child and caregivers should be separated when obtaining history regarding the sexual assault. The presence of a caregiver may alter a child’s disclosure, even when the caregiver is supportive of the child. Similarly, a child’s disclosure may be affected by overhearing the history provided by the caregivers. Additionally, this private discussion may allow caregivers the opportunity to voice concerns or emotions which they may not be comfortable or able to express with the child present. Preferably, the discussion should be held in a quiet location with as few interruptions as possible (Giardino and Finkel 2005). Prior to obtaining any history, it is essential to explain your role and the examination process, including photodocumentation and evidence collection, to the caregivers. Doing so helps to alleviate any anxiety and/or fears which the caregivers may have regarding the acute sexual assault evaluation, which is an unfamiliar process to most caregivers. When these concerns are addressed at the beginning of the encounter, the caregivers may be better able to provide a complete history. The limitations of confidentiality due to legal requirements regarding disclosures to law enforcement and child protective services should be discussed, including the possible disclosure of photodocumentation (Giardino and Finkel 2005).

Account of Events Information regarding the acute assault event is necessary in order to ensure the appropriate evidence is collected and that all acute medical needs are met. This history can also aid in interpretation of examination findings. The examiner must use their own judgment to determine how much information should be obtained directly from the child. Obtaining initial history from caregivers and investigators will aid in this determination. The child’s developmental level and cognitive function should also be considered and can often be grossly assessed in unrelated conversation prior

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to focusing on the event in question. Prior to discussing the assault with the child, the examiner should ask the caregivers what terms the child uses to refer to specific parts of the body, such as the penis or vagina. Conversations with the child should use the terminology which is familiar to the child in order to avoid confusion. The discussion should use developmentally appropriate and nonsuggestive language. Openended questions should be utilized as much as possible. For most children, “why” questions should be avoided as children may interpret such questions as implying that the child was at fault. In general, when obtaining information from the child, questioning should be limited to obtaining the minimal facts needed to complete an appropriate assessment (Jenny et al. 2013). Whenever possible, the child should be referred for a forensic interview in order to obtain additional details regarding the assault(s). A forensic interview is not the same as a medical history, and often explores the assault in more depth than is required for the forensic examination, while providing essential information to investigators (U.S. Department of Justice Office on Violence Against Women 2016). It is important to attempt to obtain information regarding the date and time of the most recent assault. In cases with multiple assaults or assailants, the timing of the most recent assault should be determined. The location(s) of the assault(s) should be elicited. In prepubertal children, up to 64% of evidence is recovered from clothing, linens, or other nonbody surfaces (Christian et al. 2000). Knowledge regarding the location of the most recent event can aid in recovery of this potential evidence. Any information which can be provided about the alleged offender(s) may aid in interpretation of forensic evidence. If the offender is known, as much information as possible about the offender should be obtained, including name, age, gender, race, and relation to the victim child. In cases with multiple offenders, information about each offender should be discussed. If the suspect was injured during the assault, details regarding the injuries should be documented. Obtaining history about the types of sexual contact is an important element in determining the type of evidence to collect and how to interpret findings. Types of sexual contact may include penetration (digital, oral, vaginal, or anal), masturbation, and nongenital contact (e.g., biting, sucking, licking, or kissing). Information about the types and frequency of events is desired, although children may only be able to tell whether something happened once or more than once. Whether or not ejaculation occurred should be discussed. If there was known ejaculation, information regarding the location(s) of ejaculation, both on the body and on nonbody surfaces, should be obtained. If it is believed that there was ejaculation on a nonbody surface, such as linens, this information should be relayed to investigators so that those materials can be recovered from the scene. The use of condoms, lubricants, masks, or gloves should be documented. Ask whether the child experienced pain or bleeding during or after the event. The use of drugs by the child or the assailant during the event should be discussed. If the child reported loss of memory or loss of consciousness, this should be documented (U.S. Department of Justice Office on Violence Against Women 2016). In the absence of historical information regarding the event, the examiner should use their clinical judgment, ancillary information, the presence of injuries, and jurisdictional policy to determine the type off evidence to collect.

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It should be determined whether there was any use of restraint, strangulation, gagging, the use of a blindfold, and the use of weapons by the assailant. This is important knowledge for the examiner in order to evaluate for other potential sites of injury that may require further evaluation or treatment. Discuss whether videos or photographs were taken or shown to the child during the assault (U.S. Department of Justice Office on Violence Against Women 2016). Question whether the child was threatened by the assailant; this information may reveal additional underlying medical or mental health needs. When possible, determine whether the child was offered something of value or a basic need (such as food) in exchange for a sexual act. If identified, this should raise concern for commercial sexual exploitation of children (CSEC), also commonly referred to as domestic minor sex trafficking. History regarding the events following the assault should also be obtained. This history is important for interpreting forensic findings, or lack thereof, following an assault. It should be determined whether the child has done any of the following since the most recent assault: bathed, showered, wiped, urinated, defecated, brushed their teeth, rinsed their mouth, eaten, drank, vomited, changed clothing, changed underwear, smoked, or vaped. Ask whether the assailant cleaned themselves or the child after the incident (U.S. Department of Justice Office on Violence Against Women 2016). Although it may be difficult for caregivers to be descriptive when discussing child sexual assault, as many details as possible should be obtained in order to guide evidence collection and interpretation as well as medical evaluation and treatment. Asking caregivers how they obtained details regarding the event may identify additional sources of historical information; this may also clarify whether there are any assumptions being made by the caregiver. Assumptions regarding details of the history should never be made by the examiner. Any unknown information should be clarified or documented as unknown. The forensic laboratory responsible for processing the evidence collected will ask that certain details regarding the assault be provided in order to assist with interpretation of evidence. The information requested may vary between laboratories, and therefore, the requirements for each state’s specific laboratory should always be reviewed by the examiner.

Additional History A complete medical history should be obtained from the caregivers. The child’s past medical history should be reviewed, with specific attention given to conditions affecting the anogenital area, including infections, inflammatory conditions (e.g., inflammatory bowel disease), and injuries. History of past sexually transmitted infections or previous sexual abuse, including timing and description of the type(s) of sexual abuse, should be elicited. Review the child’s surgical history (particularly anogenital surgery), current or recent medication use, allergies, and family history. Obtain a social history, including household members and their relation to the child. A thorough social history may identify other children at risk for abuse. A review of systems should be completed with focus on anogenital and psychosocial concerns,

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including: anogenital irritation or sensitivity, anal fissures, constipation, urinary tract infection, penile or vaginal discharge, behavior changes, and thoughts of self-harm or suicidality. The child’s sexual orientation and gender identity should also be discussed to ensure appropriate language use throughout the encounter (U.S. Department of Justice Office on Violence Against Women 2016).

The Physical Exam Whenever possible, the physical examination of the child should take place in a child-friendly setting where there are unlikely to be any interruptions. It is important that both caregivers and the child understand the examination process prior to starting the examination. The examination should be explained to the child using child-friendly language and terminology which the child can understand. Ideally, the examination should be performed by someone trained in pediatric genital examination techniques and their interpretation, and in forensic evidence collection. The equipment used for photodocumentation should also be discussed, and any questions about the confidentiality of the images addressed. Permission to complete the examination should be obtained from the child’s legal guardian(s). In general, prepubertal children have not reached the age of consent for medical examination; however, age of consent for sexual health treatment varies by state and should be considered when determining whether the child should be asked for consent. In cases where a child has not reached the age of consent, the child’s assent to examination should be obtained. The child should be allowed to determine who, if anyone, accompanies them as a chaperone during their examination (U.S. Department of Justice Office on Violence Against Women 2016). The child should never be forced to cooperate with the examination, as they have already been victimized, and the use of force during the examination would further traumatize the child. The physical examination should always be approached in an unhurried and nonthreatening manner. Distraction techniques may help a child relax and be better able to tolerate examination. Examples of distraction techniques include singing, counting, watching television, listening to music, or blowing bubbles. If the child is unable to cooperate with the examination and an emergent examination is needed due to concerns regarding the child’s health (e.g., the child is bleeding from an unknown source), then examination under anesthesia or conscious sedation should be pursued. The use of sedation for routine examinations is not recommended (U.S. Department of Justice Office on Violence Against Women 2016). It is important to note that the physical examination and forensic evidence collection occur concurrently, including some evidence, such as debris and clothing, which is collected prior to the physical examination. The steps for forensic evidence collection are discussed later in this chapter. A general physical examination should be completed, including a detailed anogenital examination. Gloves should be worn throughout the examination and should be changed when moving between body surfaces to avoid cross-contamination of evidence (U.S. Department of Justice Office on Violence Against Women 2016). A thorough oral examination should also be completed, particularly in cases

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of alleged oral penetration. The oral examination should include full visualization of the oral mucosa, including beneath the tongue, as well as the posterior pharynx. Additional lighting may be needed to fully visualize the oral cavity. Examination of the oral cavity should be completed prior to evidence collection, which is discussed later in this chapter (Kellogg and the Committee on Child Abuse and Neglect 2005b). The child should be screened for any current pain or discomfort, and extra attention should be given to any areas where the child reports pain or injury. The general physical examination includes a head to toe evaluation of the child, including documentation of the child’s appearance and behaviors. The state of the child’s clothing as well as any foreign materials (e.g., dirt or secretions) seen on the clothing should be documented. These materials may provide important forensic evidence. The process for collection of these materials will be discussed later in this chapter. The general examination allows for evaluation of nongenital injuries which may have occurred during the assault, such as bruises or abrasions. The fingernails should also be closely examined for evidence of breakage or other injury which may have occurred (Kellogg and the Committee on Child Abuse and Neglect 2005b). Photodocumentation of any nongenital injuries should be obtained with a ruler or a standard size reference (e.g., a quarter) included in the photograph for measurement of the injury. If photodocumentation is not possible, the injuries should be documented with drawings in the medical record.

The Anogenital Exam The examination of the anogenital area should be completed prior to any evidence collection or medical intervention, unless emergent intervention is required. The child should be appropriately draped during the anogenital examination, and only the body area being examined should be exposed in order to preserve the child’s modesty. The anogenital examination should be completed in such a way that it does not cause additional physical or emotional trauma to the child (Herrmann and Navratil 2004). Toluidine blue is a dye which has been used to enhance visualization of injuries on the skin and mucous membranes during acute sexual assault examinations. This dye can cause burning or discomfort when used, which may be difficult for young children to tolerate. The use of toluidine blue in prepubertal children is not recommended (U.S. Department of Justice Office on Violence Against Women 2016).

The Female Anogenital Examination When examining the prepubertal female genitalia, there are several examination positions which may be utilized. Multiple positions may be required during a single examination in order to achieve complete visualization of the genital structures. These positions include supine frog-leg, supine knee-chest, prone knee-chest, and modified lithotomy position (in which a child is examined in a lithotomy position, on the lap of a caregiver or other trusted adult). For older or taller prepubertal females,

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the use of lithotomy position may be required. The examination is typically begun in supine position. Labial separation and traction allow for visualization of the genital structures behind the labia, including the hymen, vaginal orifice, and fossa navicularis (Adams et al. 2016). Use of swabs or other implements is not recommended for the prepubertal child, as direct contact with the hymen and perihymenal tissues is very likely to be painful for the prepubertal child. Use of sterile water or saline, and changes in examination positions, are the most useful techniques to aid visualization. The female anogenital examination should be performed slowly as there may be unidentified injuries; rapid or forceful separation and traction may be painful, exacerbate preexisting injuries, or result in additional injuries. The anal examination is typically conducted in supine knee-chest position with gluteal separation in order to allow for visualization of the perianal and anal tissues. Prone knee-chest positioning can also be utilized and may be helpful when the perineal body is not well visualized. Lateral decubitus position can be used, but typically does not provide the amount of visualization achieved in the supine knee-chest position (Adams et al. 2016). The use of an anoscope is not recommended unless there are concerns for bleeding, a mass, or foreign body which cannot be visualized on routine examination. If there are concerns requiring anoscopy, the examination should be performed by a qualified health-care provider with the use of sedation or anesthesia (U.S. Department of Justice Office on Violence Against Women 2016). Refer to ▶ Chap. 40, “Genital Examination Techniques” for further details.

The Male Anogenital Examination When examining prepubertal males, the examination of the genitals, including the penis and scrotum, may be conducted in supine or upright positions. The legs should be separated enough to allow adequate manipulation and visualization of the scrotum during the testicular examination. For uncircumcised males or males with redundant foreskin, the foreskin should be retracted in order to visualize the penis. The foreskin should be retracted carefully due to the possibility of underlying adhesions, which may be accidentally torn with forceful retraction. Supine kneechest or prone knee-chest positions may be used to visualize the perineal body. The anal examination for prepubertal males is conducted in the same manner as the female anal examination, as discussed previously in this chapter (Kellogg and the Committee on Child Abuse and Neglect 2005b). Refer to ▶ Chap. 40, “Genital Examination Techniques” for further details.

Forensic Evidence Collection Policies and procedures for forensic evidence collection vary depending on the forensic laboratory will be processing the evidence. Examiners should familiarize themselves with and adhere to their state forensic laboratory’s guidelines. The

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timeframe for evidence collection varies depending on the type of alleged assault (Donaruma-Kwoh et al. 2016). Examiners should refer to their state forensic laboratory’s policies when determining whether a child is within the timeframe for evidence collection. Unique case circumstances (e.g., presence of acute genital injuries or recent kidnapping) should be considered when determining whether an acute forensic examination and evidence collection are appropriate, particularly in cases in which the timing and/or type of assault is less clear. In general, the history and timing of events in conjunction with jurisdictional policies will dictate the types of evidence which will be collected. In all cases, the child’s medical needs should be considered when determining how best to proceed. The need for emergency treatment always takes precedence over evidence collection (Herrmann and Navratil 2004; U.S. Department of Justice Office on Violence Against Women 2016). Prior to evidence collection, consent should be obtained from the child’s legal guardian and assent should be obtained from the child. Following proper procedure throughout the evidence collection process is critical to ensure that suitable specimens are obtained and maintained, and to ensure that the evidence is admissible during trial. Procedures for specimen collection, packaging, labeling, sealing, storage, and chain of custody are determined by the state forensic laboratory responsible for processing the evidence. If there are any questions regarding the guidelines, the laboratory should be contacted for further guidance. In general, chain of custody must be documented from the time the evidence is collected until it is released to the investigative agency. Procedures should be put in place for storage of forensic evidence in the event that law enforcement is unable to pick up the evidence immediately after the examination (U.S. Department of Justice Office on Violence Against Women 2016). Gloves should be worn throughout the examination and evidence collection. Gloves should be changed frequently, including each time a different body area is examined. When samples are obtained for both forensic and medical testing, samples for forensic testing should be obtained first and kept separate from medical specimens. Medical and toxicology specimens, discussed later in this chapter, are processed separately from the forensic evidence. All forensic evidence should be placed into a sealed container, most commonly the evidence collection kit. Evidence collected during the examination should be stored in paper packages or envelopes. The use of plastic containers is not recommended. Plastic retains moisture, which encourages growth of mold and/or bacteria and may degrade the sample. All wet evidence (e.g., condoms) should be refrigerated. The forensic laboratory may require that wet specimens be dried prior to packaging. When drying wet specimens, drying should be done at room temperature in a clean area. A swab dryer may also be used. If a foreign substance is used during examination (e.g., betadine), such use should be documented in order to aid in interpretation of evidence (U.S. Department of Justice Office on Violence Against Women 2016). There are two types of evidence which may be recovered during the forensic examination: transfer evidence and identification evidence. Transfer evidence, also called associative evidence, includes the foreign materials found on the child’s body or clothing which may have been transferred from the scene of the assault or directly

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from the assailant. Identification evidence consists of evidence which may be used to identify the perpetrator, including sperm or other DNA-containing bodily fluids (Thackeray et al. 2011).

Steps for Evidence Collection The types of forensic evidence samples collected vary depending on the details of the event, timing of the abuse, and information provided by investigative agencies. Jurisdictional policies should be followed when determining which forensic samples to collect. General guidelines for forensic evidence collection have been established; however, there is variation in the specific guidelines used by each forensic laboratory, including differences in collection techniques, the types of swabs used (e.g., cotton versus synthetic swabs), and storage procedures. This chapter will provide general guidance on the collection of forensic samples, but specific policies established by the forensic laboratory responsible for processing the collected specimens should always be followed. Chain of custody should be ensured throughout the collection process. A list of the types of samples which may be collected during the acute sexual assault examination is seen in Table 1 (U.S. Department of Justice Office on Violence Against Women 2016). If the victim is wearing the same clothing worn at the time of the assault, it is generally recommended that the clothing be collected. If clothing will be collected, procedures should be followed to collect any evidence which may fall off the clothing. Thus, the first step in evidence collection involves collection of foreign Table 1 Types of samples collected during an acute sexual assault examination The following samples may be collected, when appropriate, for forensic evidence during the acute sexual assault examination of the prepubertal child: Foreign material dislodged while the victim is undressing Clothing, underwear, and/or diaper from the victim Debris (e.g., dirt, fibers) from the victim’s body Foreign materials (e.g., saliva, semen) from the surface of the victim’s body Hair combings (e.g., head, pubic) Hair reference samples Oral swabs and smear Buccal swab reference Genital swabs and smears, including: External genital swabs and smear Vaginal swabs and smear Penile swabs and smear Perianal swabs and smear Anorectal swabs and smear Toxicology samples for suspected drug or alcohol-facilitated sexual assault Medical specimens to identify sexually transmitted infections (STIs)

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material which may become dislodged while the victim is undressing. Most jurisdictions recommend the use of a paper debris collection cloth. A clean bed sheet should be laid on the floor with the debris collection cloth laid on top of the sheet in order to prevent the debris collection cloth from touching the exam room floor. The child undresses while standing in the center of the debris collection cloth. The cloth should be folded in such a manner that no dislodged evidence is lost. The victim’s clothing should be collected and stored according to jurisdictional policy. The need to collect items such as coats and shoes should be carefully evaluated, as loss of these items may place a financial strain on the family. Clothing which is stained or damaged may be used to support the history of events provided. Do not cut or rip the clothing as this may distort interpretation of any damages to the clothing caused during the assault. Do not shake out the clothing during collection due to the risk for loss of evidence. Wet clothing should be packaged and stored according to local jurisdictional policy (Christian et al. 2000; U.S. Department of Justice Office on Violence Against Women 2016). When possible, replacement clothing may be offered to the victim by coordinating with a local Child Advocacy Center (CAC) or Victim Advocacy Center (VAC). If the child is no longer wearing the clothing worn at the time of the assault, investigators should be notified so that they can recover the clothing worn. The underwear, diaper, or pull-up worn by the victim at the time of the forensic examination should be collected, even if the child has changed clothing since the assault, due to the possible presence of seminal fluid or other identification evidence. If the child has changed clothing since the assault, investigators should be notified so that the original underwear, diaper, or pull-up can be recovered. Any other material in contact with the genitals (e.g., any absorbent padding which may have been used) should also be collected (U.S. Department of Justice Office on Violence Against Women 2016). The victim’s skin and hair should be examined for debris and foreign materials. Any foreign debris (e.g., dirt, fibers, hair, etc.) found on the victim’s body during examination should be collected prior to obtaining oral, genital, and anorectal samples. Debris on the victim’s body may include transfer evidence or identification evidence and may aid in corroborating the location of the assault as well as identifying the offender. Collection of fingernail scrapings and/or swabs is typically reserved for assault during which the victim describes scratching the offender or when there is visible material beneath the fingernails. If the fingernails are damaged, photographs of the fingernails should be obtained prior to obtaining samples. Scrapings or swabs of the fingernails should be performed using the equipment provided in the evidence collection kit. Collection of fingernail clippings is not universally recommended and may only be necessary when the fingernails are broken during the assault (U.S. Department of Justice Office on Violence Against Women 2016). Other foreign materials on the body surface may include DNA-containing materials deposited from the assailant, such as saliva, semen, or other bodily fluids. DNAcontaining materials may also be transferred to the body surface when a child is touched or restrained by the assailant. Collection of foreign materials may be guided

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by the history of events (e.g., the victim indicates a body surface which was licked by the assailant) or by the presence of visualized foreign materials, even if not accounted for in the history of events. The use of an alternative light source can be used to aid in the identification of DNA-containing foreign materials, which may fluoresce under short-wave blue light or long-wave ultraviolet (UV) light. The use of alternative light sources will be discussed later in this chapter. Collection of potential DNA-containing materials on the body surface should be performed by swabbing the area of concern using swabs moistened with sterile water according to jurisdictional policy. Any bite marks which are present should be swabbed due to possible presence of saliva. When collecting evidence from bite marks, the areas inside and around the arches of the bite mark should also be swabbed in order to recover DNAcontaining material from sites where the lips and tongues of the biter may have touched (U.S. Department of Justice Office on Violence Against Women 2016). Head hair combings should be considered whenever there is debris, secretions, or other foreign material are seen in the victim’s hair, as this may aid in recovery of foreign materials or hair from the assailant. Pubic hair combings can recover pubic hair transferred from the assailant and may be indicated in some jurisdictions when assault involved the victim’s genitals. To collect foreign materials from hair combings, a collection paper is placed beneath the body area being combed, the hair is combed using a comb provided in the evidence collection kit, and any foreign materials dislodged by combing fall onto the collection paper. The comb is then placed in the center of the collection cloth, which is folded in such a manner that the comb and any foreign materials are retained. The sample is packaged, labeled, and sealed according to jurisdictional policy. Hair reference samples from the victim, including pubic and head hair references, are not routinely collected in prepubertal children. If required, jurisdictional policies for collection should be followed. Hair reference samples may be useful when trying to determine whether hairs collected during forensic examination are foreign to the victim. If a hair reference is needed but was not collected initially, the reference sample may be collected on a later date. Patients and the caretakers should be informed about the purpose for collecting a reference sample, and the potential need to collect a sample in the future if no sample was collected during the examination (U.S. Department of Justice Office on Violence Against Women 2016). The next steps in evidence collection include the collection of external genital and perianal swabs as well as oral, genital, and anorectal swabs. Some jurisdictions recommend routine collection of swabs from all three sites (oral, genital, and anorectal), but other jurisdictions recommend obtaining samples only from the body orifices involved in the assault based on the account of events. It is important to remember that a trauma-informed approach should guide all decision-making, and the child’s ability to tolerate evidence collection should always be considered. The number and types of swabs used, the swabbing technique, the use of moistened swabs, the packaging of swabs, and the time frame for collection vary between jurisdictions. Some jurisdictions require that a smear be made on a microscope slide in addition to collection of the swabs. Table 2 provides an overview of indications and steps for collection of oral, external genital, genital, perianal, and anorectal

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Table 2 Collection of oral, external genital, genital, perianal, and anorectal swabs in prepubertal children Forensic sample specimen Oral swabs

Buccal swabs

Female external genital swabs

Vaginal swabs

Penile swabs

Indications Suspected oral-to-genital contact with or without ejaculation

Patient reference standard Preferred standard for cases with forensic evidence collection May be contaminated with assailant DNA-containing material in cases of suspected oral penetration Suspected: Penile–vaginal penetration Oral-to-genital contact Other genital-to-genital contact Other contact that could have left DNA-containing material

Suspected: Penile–vaginal penetration Oral-to-genital contact Other genital-to-genital contact Other contact that could have left DNA-containing material Generally, not indicated in prepubertal females Only obtained when child also has a medical necessity for anesthesia (e.g., suspected internal injury) Suspected: Penile–vaginal penetration Penile–anorectal contact Oral-to-genital contact Other genital-to-genital contact

Collection instructions Use dry swabs to swab the entire oral cavity, including under the tongue, around the teeth, and between the gums and cheeks Some jurisdictions include swabs of the lips and perioral skin using swabs moistened according to protocol with sterile water Smear sample onto a microscope slide when indicated by policy Obtain before allowing the child to eat or drink, if possible Obtain before buccal swabs Expose the inner cheek and swab with gentle pressure using sterile swabs Obtain after oral swabs. Rinse mouth with tap water prior to obtaining buccal swabs Use swabs moistened according to protocol with sterile water. Swab the external area (e.g., skin) of the female genitalia Swab onto the internal thighs if indicated by policy or history of the assault Smear sample onto a microscope slide when indicated by policy Obtain before vaginal swabs Avoid contact with the hymen Samples should be obtained under anesthesia in consultation with appropriate pediatric specialists Use sterile swabs according to jurisdictional protocol Smear sample onto a microscope slide when indicated by policy Obtain after external genital swabs

Use swabs moistened according to protocol with sterile water. Swab the external genitalia according to protocol, including the penile shaft, prepuce (foreskin), glans, and (continued)

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Table 2 (continued) Forensic sample specimen

Perianal swabs

Anorectal swabs

Indications

Collection instructions

Other contact that could have left DNA-containing material

scrotum Swab onto the internal thighs if indicated by policy or history of the assault Smear sample onto a microscope slide when indicated by policy Avoid contact with the urethral meatus Use swabs moistened according to protocol with sterile water. Swab the perianal area and the buttocks adjacent to the anal verge Smear sample onto a microscope slide when indicated by policy

Suspected: Penile–anorectal contact Oral-to-anal contact or penetration Digital or object contact or penetration by assailant Contact that could have left DNAcontaining material (including leakage of seminal fluid from vaginal area) Suspected: Penile–anorectal contact Oral-to-anal contact or penetration Digital or object contact or penetration by assailant Contact that could have left DNAcontaining material

Use swabs moistened according to protocol with sterile water. Rotate the swabs while swabbing the anal canal Smear sample onto a microscope slide when indicated by policy

swabs and smears. Jurisdictional policies should always be followed to ensure that the evidence is collected appropriately. All samples should be labeled, packaged, sealed, and stored according to jurisdictional policies (U.S. Department of Justice Office on Violence Against Women 2016). The external genital and perianal swabs should be obtained prior to collection of internal swabs due to the potential for cross contamination of DNA. A buccal swab is generally the preferred DNA reference standard for prepubertal children. In cases of alleged oral-to-genital contact, the oral sample for forensic evidence collection should be obtained prior to the buccal swab standard. The child should rinse their mouth with tap water between collection of the two samples to minimize the likelihood that the buccal sample will be contaminated with DNA-containing material from the offender. Blood samples as a reference standard are generally not required when a buccal swab is obtained. Blood samples are not recommended in the prepubertal population (U.S. Department of Justice Office on Violence Against Women 2016). Vaginal swabs are generally not recommended in prepubertal females due to the low yield of forensic evidence. Additionally, this collection technique is painful in the prepubertal female due to the lack of estrogen. If a victim requires anesthesia due to a medical necessity, such as concern for an internal injury, then internal vaginal

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swabs may be obtained with the use of anesthesia. The medical needs of the child should take precedence over forensic evidence collection. The use of a wet mount is recommended in certain jurisdictions to evaluate vaginal samples for the presence of motile and nonmotile sperm. In vaginal samples, motile sperm rarely persist for more than 3 h and may stop moving within 30 min. Due to this narrow time frame, the wet mount may be included in some protocols. Many jurisdictions do not rely on examiners to perform the wet mount, as the ability to detect motile sperm is directly affected by the experience level of the examiner interpreting the test. To prepare a wet mount, a drop of normal saline should be placed on a microscope slide, and the vaginal swab should be rolled in the drop. The slide is then evaluated using a microscope. The slide and swab should be dried and stored in the evidence collection kit according to jurisdictional policy (U.S. Department of Justice Office on Violence Against Women 2016).

Photodocumentation Accurate documentation of the physical exam findings, including descriptions of any injuries, is important when documenting the forensic medical examination. Whenever possible, photodocumentation of any injuries, including anogenital and nongenital injuries, should be obtained. Photodocumentation provides visual forensic evidence of the examination findings as they appeared at the time of the examination, and can help avoid the need for additional examinations to confirm the exam findings (Green 2013). Photographs should be obtained by a pediatric examiner, preferably examiners who have undergone training on photodocumentation in child sexual abuse cases (U.S. Department of Justice Office on Violence Against Women 2016). There are a variety of photodocumentation techniques and technology which may be utilized. Injuries may be documented using digital or nondigital devices, using video and/or still photography. Although still photography has been more commonly utilized in the past, newer evidence suggests that video photography may more accurately capture physical exam findings. If photodocumentation of injuries cannot be obtained, the injuries should be documented using diagrams. There is variation in practice regarding photodocumentation for a child without injuries; local jurisdictional policies should be followed (Green 2013; U.S. Department of Justice Office on Violence Against Women 2016). If possible, providers performing sexual assault examinations should seek out methods to have their examinations and/or photodocumentation peer reviewed. A peer review process involving other experienced providers can help confirm findings and may identify areas for ongoing education. Refer to ▶ Chap. 40, “Genital Examination Techniques” for additional information on photodocumentation. The photodocumentation process should be discussed with the patient and caregivers. Patient comfort and privacy should be considered while obtaining images. Images should be labeled with the patient’s name and the date on which the images were obtained. There should be adequate lighting to ensure clear visualization of the injuries. A ruler or a standard size reference (e.g., a quarter) should be included in the

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body images in order to demonstrate the size of the injuries. Wide view and close up images should be obtained to ensure that the injury is well visualized and that the body location on which the injury is found can also be identified. Local protocols should be established and followed to ensure that all images obtained are stored in a secure manner (U.S. Department of Justice Office on Violence Against Women 2016).

Alternative Light Sources Some forensic protocols recommend the use of alternative light sources to aid in the collection of additional forensic samples. Semen stains on the body surface or clothing may fluoresce under certain wavelengths, and these areas can then be targeted for forensic sample recovery. Jurisdictional protocols should be followed when determining whether the use of alternative light sources is recommended (U.S. Department of Justice Office on Violence Against Women 2016). The Wood’s lamp produces ultraviolet light with wavelengths ranging from 320 to 400 nm, which may cause a white to yellow-green fluorescence in semen. The overall sensitivity for semen detection with a Wood’s lamp is low, and commonly results in a false negative. Semen maximally fluoresces at wavelengths between 450 and 490 nm. Wood’s lamps with shorter wavelengths may not cause semen to fluoresce. The fluorescence of known semen samples has been shown to be transient and may fade within 28 h (Gabby et al. 1992). Absence of fluorescence has also been documented, even when attempting to cause fluorescence in known semen samples. Wood’s lamps may also cause fluorescence of several other nonsemen substances, including many substances which are commonly found on children, such as A&D Ointment, Barrier Cream, and bacitracin (Santucci et al. 1999). Urine may also fluoresce with a white to yellow-green color, similar to semen, and has been noted to fluoresce much longer than semen, up to 80 h (Gabby et al. 1992). Due to the number of other substances which fluoresce, often better than semen, there are also many false positives associated with the use of a Wood’s lamp. In summary, although a Wood’s lamp can result in identification of bodily fluids which may not otherwise be detected, the presence of fluorescence should not be considered definitive evidence that semen is present, and all samples recovered should undergo further forensic analysis, as other substances can cause fluorescence with a Wood’s lamp. The use of light sources with wavelengths between 450 and 490 nm, the same spectrum in which semen fluoresces, maximizes sensitivity and specificity in detection of semen. Visible blue light may enhance visualization of semen as well as skin changes associated with injury. To visualize semen fluorescence, the light source must be held very close to the skin (45 kg Ceftriaxone 250 mg, intramuscular, single dose

Azithromycin 1 g, by mouth, single dose (regardless of age if child meets weight requirement) Doxycycline 100 mg, by mouth, twice daily, for 7 days if child 8 years old Metronidazole 45 mg/kg/day, by Metronidazole 2 g, by mouth, single mouth, divided into 3 doses, for dose, or 7 days (maximum dose of 2 g/day) Tinidazole 2 g, by mouth, single dose Acyclovir 80 mg/kg/day, by mouth, Acyclovir 400 mg by mouth, 3 times divided into 4 doses, for 7–10 days per day, for 7–10 days, or (maximum dose 3.2 g/day), OR Acyclovir 200 mg by mouth, 5 times Valacyclovir 40 mg/kg/day, by mouth, per day, for 7–10 days, or divided into 2 doses, for 7–10 days Valacyclovir 1 g, by mouth, twice (maximum dose 2 g/day) daily, for 10 days, or Famciclovir 250 mg, by mouth, 3 times per day, for 7–10 days Treatment for all infants and children > 1 month of age Primary, secondary, and early latent syphilis: Penicillin G benzathine 50,000 U/ kg, IM, in a single dose (maximum dose 2.4 million U) Late latent syphilis: Penicillin G benzathine 50,000 U/kg, IM, once per week for 3 doses (maximum single dose 2.4 million U; maximum cumulative dose 7.2 million U) Neurosyphilis: Aqueous crystalline penicillin G 50,000 U/kg, IV, every 4–6 h for 10–14 days (maximum dose 24 million U per day)

Adapted from Red Book ® 2018 If the child has not been previously immunized for hepatitis B and the offender’s hepatitis B status is unknown, the first dose of the hepatitis B vaccine series should be given during the initial examination, with follow-up doses administered 1–2 months and 4–6 months after the first dose. If the offender is known to be hepatitis B surface antigen (HBsAg) positive and the child is not vaccinated for hepatitis B, both the hepatitis B vaccine and hepatitis B immunoglobulin (HGIB) should be given. If the child has been vaccinated for hepatitis B, but the offender is known to be HBsAg positive, a single booster dose of the hepatitis B vaccine should be administered. If the child is fully vaccinated for hepatitis B and the offender’s hepatitis B status is unknown, no further intervention is required. The HPV vaccine series should be initiated or completed (if already begun) for victims of sexual assault who are 9 years of age or older regardless of gender

laboratory evaluation (AAP Red Book® 2018a). Most, if not all, practitioners forgo collection of a urethral swab in boys, instead choosing to obtain meatal specimens if discharge is present. Similar to chlamydia, anorectal and pharyngeal infections with gonorrhea are often asymptomatic. There is a growing body of evidence which suggests that many cases of gonorrhea may be missed if testing at extragenital sites (oropharynx, rectum) is not performed, so routine testing at multiple sites is recommended (Kellogg et al. 2018; Uprety and Cardenas 2019). Among prepubertal

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children, anorectal or pharyngeal infections are frequently asymptomatic, and so routine testing is recommended (Workowski et al. 2015). A chart review of 1319 children and adolescents who were screened for gonorrhea and chlamydia at three sites (urine, oropharynx, rectum) indicated that nearly 10% of patients tested had at least one infected site. Most patients with a positive anal or oral test did not disclose that the alleged perpetrator had genital contact with the infected site (Kellogg et al. 2018). Among 655 patients ages 2 to 17 years who had testing for gonorrhea and chlamydia of urine, oropharynx, and rectum, gonorrhea infection rates were 0% to 25.8% (by age group); there was a higher prevalence among adolescents. The rectum was the site with the highest prevalence of gonorrhea infection (10.3%), with the oropharynx having the second highest prevalence of gonorrhea infection, at 9.7%; only 1.9% of cases had urine infection (Uprety and Cardenas 2019). These data imply that most cases of gonorrhea infection are missed if only urine is tested. NAATs can be used on urine and vaginal specimens in girls, with urine being the most common testing method in prepubertal females; urine may have slightly reduced performance compared to cervical or vaginal swabs (AAP Red Book ® 2018). NAATs have both high sensitivity and high specificity, particularly when compared to older methods such as DNA probe or DFA (AAP Red Book® 2018). NAATs are available for endocervical, vaginal, and male urethral swabs; urine from males or females (dirty specimen); and liquid cytology specimens (AAP Red Book® 2018). NAATs are not FDA approved for use in boys because of the lack of data, and culture is still the testing modality recommended by the CDC for detection of urogenital gonorrhea in boys, and at extragenital sites in boys and girls (Workowski et al. 2015). However, NAATs are more widely available and are more sensitive than culture. The AAP recommends the use of NAATs when evaluating children and adolescents for gonorrhea (Jenny et al. 2013). Caution must be used in interpretation of positive tests from oropharyngeal sites, as nongonococcal Neisseria species can cross-react with the swabs (AAP Red Book® 2018a, c). Diagnostic labs have to validate their assays for N. gonorrhoeae from extragenital sites prior to use of NAATs for that purpose (Uprety and Cardenas 2019). In low prevalence populations such as prepubertal children, there is a small but real possibility of a false-positive test using NAATs (AAP Red Book® 2018a). For this reason, it is always vital to obtain repeat testing for confirmation when a child has a positive result using NAATs; if specimens are held in the lab, performance of confirmatory testing is facilitated. Culture is recommended as a confirmatory test (AAP Red Book® 2018c), but many labs no longer offer culture tests (Jenny et al. 2013). When a positive result is found, many use additional NAAT tests to confirm an initial positive result. The preferred modality is to have the lab repeat the test in a different gene sequence of the organism. The laboratory performing the test may have other confirmation methods for positive results. If a diagnosis of gonorrhea is made in a prepubertal child, screening for additional STIs should be performed, including chlamydia (which is often tested along with gonorrhea using NAATs), HIV, syphilis, and trichomoniasis; an investigation should also be initiated by police and/or child protection, due to concerns for sexual abuse/ assault.

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Treatment of gonorrhea is with 250 mg of ceftriaxone, intramuscularly, in combination with azithromycin (1 gram) for a child who weighs more than 45 kg (100 pounds). For children who weigh less than or equal to 100 pounds, ceftriaxone is administered in a single dose at 25–50 mg/kg (no more than 125 mg), IV or IM, as referenced in Table 2. Although there are recommendations for obtaining cultures approximately 2 weeks after treatment is completed as a test of cure (Workowski et al. 2015), there are many practical difficulties posed by obtaining cultures. Instead, repeat NAATs may be obtained several weeks after treatment.

Syphilis Syphilis is caused by Treponema pallidum, a spirochete which only survives briefly outside its host. It causes neonatal infections, which can have severe manifestations in affected infants. When the infection is acquired, the incubation period ranges from 10 to 90 days but is typically 3 weeks. Acquired infection is contracted through direct sexual contact with the ulcerated lesions of the skin or mucous membranes of infected people. The primary stage of syphilis is manifested by one or more painless indurated chancres or ulcers (Fig. 15); it emerges approximately 3 weeks after exposure and usually heals within 3 weeks. The ulcers are most often on the genitals but may be in other areas of the body (e.g., anal, oral regions), depending upon the location of sexual contact leading to the infection. Painless lymphadenopathy in the affected area is common (AAP Red Book ® 2018d). If syphilis is not detected in the primary stage, it can progress to the secondary or tertiary stages, which has important implications for the child’s future health. The secondary stage of syphilis starts 1 to 2 months later, with symptoms of fever, sore throat, muscle aches, rash, and generalized lymphadenopathy. The rash is generalized and often includes the palms and soles. Malaise, headache, alopecia, and arthralgia can also be present. Hypertrophic lesions (condyloma lata) are present in moist areas around the vulva or anus and can be mistaken for condyloma acuminata due to infection with human papillomavirus (HPV). These lesions are highly infectious, and direct sexual contact with these lesions is one of the primary ways this infection is spread. This stage resolves within 3 to 12 weeks, leaving the person asymptomatic (although some may have occasional recurrence of symptoms of Fig. 15 Chancre of primary syphilis in a 16-year-old female with a history of consensual and nonconsensual sexual activity

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secondary syphilis over the next few years). If untreated, syphilis can progress to the latent stage, in which the patient has serologic evidence of disease, but does not have symptoms. Those with a latent stage of less than 1 year in duration are considered to have early latent syphilis; those whose latent stage is longer than 1 year, or of unknown duration, are classified as late latent syphilis. The patient with tertiary syphilis, which occurs 15 to 30 years after the initial infection, can have multiple manifestations, including formation of gumma (soft noncancerous growths), cardiovascular involvement, and/or neurologic involvement (AAP Red Book ® 2018d). Screening for syphilis generally begins with use of serologic non-treponemal tests such as RPR (rapid plasma reagin) and VDRL (Venereal Disease Research Laboratory). These inexpensive tests are less sensitive in early and late disease, and so if there is a high clinical suspicion, additional tests should be considered. RPR and VDRL are negative after treatment has taken place. If lesions are present, a DFA (direct free antigen) test can be performed; specimen collection requirements should be checked with the laboratory performing the test, but generally, the lesion has to be cleaned, then a swab of the base of the lesion will need to be applied to a slide. The slide should be dried prior to placement in a holder and transport to a lab for testing (Miller et al. 2018). If there is a positive result on one of the non-treponemal screening tests, then further testing with a serum treponemal test (FTA-ABS (fluorescent treponemal antibody absorption), EIA (enzyme immunoassay)/CIA (chemiluminescence assay), or TPPA (Treponema pallidum particle agglutination)) should be performed. These tests are more expensive and more specific than the non-treponemal tests. Treponemal tests evaluate the sample for the presence of spirochetes and will be positive for life in someone who has had syphilis. Such tests will be positive if someone has been positive, treated, or partially treated; however, they can be falsely positive in patients with certain medical conditions, or with a low likelihood of infection. Although the conventional diagnostic approach is to screen with a nontreponemal [RPR, VDRL] test, then use treponemal tests for confirmation, some high-volume clinical labs will begin with treponemal tests, then use non-treponemal tests for confirmation. Syphilis titers should be monitored using the same type of test and/or laboratory. A person with syphilis who also has HIV infection may have unusual serologic responses (Miller et al. 2018). The preferred treatment of early acquired syphilis (primary, secondary, or early latent syphilis) for children and adults is with penicillin G benzathine in a single intramuscular dose (see Table 2). Either late latent or tertiary syphilis should be treated with penicillin G benzathine, in three doses. Any syphilis treatment should occur with the guidance of a specialist in pediatric infectious diseases.

Human Immunodeficiency Virus (HIV) HIV is a cytopathic lentivirus in the Retroviridae family which causes a viral illness resulting in a wide variety of clinical manifestations related to immune system dysfunction, including repetitive infections, neurologic manifestations, progression to AIDS, and malignant neoplasms (rarely seen in children). There are two types of HIV, HIV-1 and HIV-2; HIV-1 is the type most commonly seen in the United States, with HIV-2 most frequently seen in West Africa.

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Acute retroviral syndrome develops in 50% to 90% of adolescents and adults within the first few weeks after infection. Acute retroviral syndrome is an acute period of illness with nonspecific symptoms such as lymphadenopathy, skin rash, fever, and malaise. Combination antiretroviral therapy has greatly reduced the frequency of opportunistic infections and increased the life span of those affected by HIV. It is considered diagnostic of sexual abuse when HIV infection is diagnosed in a prepubertal child who is past the neonatal period. The body fluids which are involved in transmission of HIV are breast milk, semen, cervical/vaginal secretions, and blood. The methods of transmission are sexual contact (vaginal, anal, or orogenital); mucous membrane exposure to infected body fluids; percutaneous (e.g., needlestick with a contaminated needle); during pregnancy, childbirth, or breastfeeding; or transfusion of infected blood products. For all children suspected to have experienced penetrating trauma, for whom there was an unknown assailant, for an assailant suspected or known to be HIV positive, and for children with mucosal injury, serologic testing for HIV is recommended. Serology testing using immunoassays is widely used for screening in children ages 24 months and older; in children younger than 24 months, methods for detecting the virus or viral nucleic acids are more effective at diagnosing HIV infection. Many diagnostic tests assess for HIV antibody and p24 antigen; they are highly sensitive and specific. Plasma HIV RNA and DNA assays are also in use. The need for HIV testing should be considered on a case-by-case basis in prepubertal children and tailored to the circumstances. Multiple factors should be taken into account, including mucosal trauma and other circumstances of the assault, local epidemiology, and family wishes. When testing is indicated, repeat tests should be performed 6 weeks, 3 months, and 6 months post-assault to assess for seroconversion. If the child presents acutely for care, HIV prophylaxis should be considered, with the guidance of a specialist in pediatric infectious diseases; the nonoccupational postexposure prophylaxis (PEP) guidelines address these concerns in detail Centers for Disease Control and Prevention (2016). These recommendations are explored in more detail in the chapter Forensic Analysis of Child Sexual Abuse. Consultation with a pediatric infectious diseases specialist is highly recommended for all cases for whom prophylaxis is administered and for children with positive or indeterminate results with serology testing (AAP Red Book® 2018e).

Sexually Transmitted Infections Highly Suspicious for Child Sexual Abuse Trichomonas Trichomoniasis is caused by Trichomonas vaginalis, a flagellated protozoan. The incubation period averages 1 week but ranges from 5 to 28 days. The prevalence of trichomoniasis was estimated at 2.1% among females ages 14 to 19 years in the early 2000s, making it the most common nonviral sexually transmitted infection in the

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United States and globally. Most affected individuals are asymptomatic; when symptoms are present, vulvovaginal irritation and pruritus, vaginal discharge, dysuria, and lower abdominal pain can occur. This condition can cause vaginal discharge of multiple types, but the classic description of the discharge is frothy yellowgreen discharge which is described as having a fishy odor (AAP Red Book ® 2018f). When trichomoniasis is diagnosed in a prepubertal child who is past the neonatal period, there is a high suspicion for child sex abuse. Methods used to diagnose trichomoniasis include culture using a culture medium which is specific to trichomoniasis, wet mount, and NAATs. The NAATs are highly sensitive and specific, and the wet mount is the least sensitive of these methods. The culture media have sensitivity ranging from 75% to 90% in females, with lower sensitivity among males. Although NAATs may improve the detection of T. vaginalis when compared to wet mount or culture, NAATs are not currently recommended for screening of trichomoniasis in prepubertal children due to discrepancies in results obtained when trichomoniasis was assessed using various testing modalities among prepubertal girls (Sena et al. 2015). Care must be taken to distinguish T. vaginalis from another trichomonas species, T. hominis, which causes gastrointestinal symptoms, including diarrhea. When using testing methods which do not rely on RNA or DNA, T. hominis can be confused with T. vaginalis.

Sexually Transmitted Infections (STIs) Suspicious for Child Sexual Abuse The infections in this section can be transmitted by a variety of means, including sexual and nonsexual contact (Adams et al. 2018, AAP Red Book® 2018a).

Herpes When genital herpes is diagnosed in a prepubertal child who is past the neonatal period, there is suspicion for child abuse. A careful assessment is needed, with involvement of investigative agencies. Herpes simplex virus has two variants, herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2). Until recent years, genital herpes was most often caused by HSV-2, but now HSV-1 accounts for over half of the cases of herpes infection in the United States. Most cases of genital herpes infection are asymptomatic, and so most of those affected by it are unaware that they have the condition. Once a person has been infected with herpes, the infection persists for life. There can be periodic reactivation of the infection; most often, the reactivated infection is asymptomatic but can cause recurrent symptoms. Shedding of virus occurs during reactivation. Genital infections with HSV-2 are more likely to recur than genital HSV-1 infections. HSV infections are widespread and can be transmitted by a person who has a primary or recurrent infection. It can be spread by a person who has symptoms, as well as by those who do not. The incubation period for herpes contracted past the neonatal period ranges from 2 days to 2 weeks (AAP Red Book® 2018g).

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Fig. 16 (a, b) Herpes simplex virus lesions in a 7-year-old female. No abuse disclosure was made

There are several manifestations of herpes infection. Vesicles (either singly or in groups) can appear in the perioral region or in the anogenital region (on penis, scrotum, thighs, buttocks, perianal region, vulva, cervix, or back) (Fig. 16a, b). Herpetic gingivostomatitis is the most common form of herpes infection in childhood; this infection results in fever, irritability, tender submandibular adenopathy, and oral ulcers. Herpetic whitlow (a skin infection affecting the distal fingers), herpes gladiatorum (a skin infection among wrestlers), and herpes rugbiorum (herpes skin infection in rugby players) are all transmitted by skin-to-skin contact. There are multiple testing methods in use which can establish the diagnosis of herpes infection. A traditional cell culture (rather than viral culture) can be used, as herpes virus grows well. Positive culture results can be confirmed with fluorescent antibody staining, enzyme immunoassays, or monolayer culture with typing. HSV polymerase chain reaction (PCR) assay and HSV culture are the preferred methods to detect HSV in genital lesions (AAP Red Book ® 2018g). NAATs are often used for testing of suspicious lesions. A scraping or aspirate of the lesion should be handled in accordance with the specimen collection requirements of the testing laboratory. A DFA may also be used. If testing is desired to detect the presence of atypical varicella-zoster virus (VZV), which may cause anogenital lesions, then DFA and NAAT are more sensitive than culture. Viral culture is rarely used. For all of these testing methods, the base of the lesion must be scraped in order to avoid obtaining a false-negative result. The medical provider must check with the laboratory regarding allowable specimen type (Miller et al. 2018). Antibodies to HSV infection develop within the first several weeks after infection. Antibody testing may be useful in confirming a clinical diagnosis of HSV infection. Antibody tests determine the subtype causing symptoms, which may be useful in symptom management. However, caution should be used in interpreting the results of antibody tests, as such tests cannot determine who transmitted the infection to the child. Primary outbreaks of HSV may be treated with oral acyclovir, valacyclovir, or famciclovir depending on the child’s age and weight (see Table 2). Treatment of a

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primary infection may shorten the duration of illness and viral shedding, but does not affect the likelihood of reactivation (AAP Red Book® 2018g).

Condylomata Acuminata (Anogenital Warts) Condyloma, or anogenital warts, is caused by human papillomavirus (HPV). This is another condition for which diagnosis in a prepubertal child past the neonatal period raises concern for sexual abuse. The warts are skin-colored and vary greatly in size. They can be found on the penis, scrotum, and anal/perianal area in males. In females, they may be found on the labia and anal/perianal region. It is more common for them to be outside the vagina, but they can occur in the vagina or on the cervix. Although typically painless, they may cause itching, burning, bleeding, or pain in the area. Seventy-nine million people in the United States have HPV infection, with another 14 million new cases annually (AAP Red Book ® 2018h). The prevalence of nongenital HPV infections is as high as 50% in school-aged children; it is spread by casual contact, and autoinoculation can also spread warts (AAP Red Book ® 2018h). Genital infections are primarily spread by skin-to-skin contact, usually sexual contact. It is possible to contract genital warts during the birth process, and so vertical transmission must be considered in a child under age 5 years who has anogenital warts (Adams et al. 2018). Although many people are asymptomatic and are unaware that they have been infected with HPV, it can elicit helpful information if the patient’s mother is asked about her own history of past lesions, abnormal Pap smears, cryosurgery, and LEEP or other genital procedures; positive responses to these questions suggest that mother has a personal history of HPV. The patient’s mother should also be asked whether she or the patient’s father had any anogenital warts prior to or during her pregnancy with the patient. However, the absence of these elements does not exclude the possibility of vertical transmission of condyloma, as tens of millions of people in the United States alone have asymptomatic infections. Care must also be taken to distinguish condylomata acuminata from congenital lesions or other conditions (AAP Red Book ® 2018h) (Figs. 17, 18). Anogenital warts are generally diagnosed by visual inspection. Clinical testing for HPV subtypes that have a higher risk for neoplastic development may be used in women age 30 years or older, but are not clinically relevant in the management of the prepubertal child.

Healing of Anogenital Traumatic Injuries Studies examining the healing of anogenital injuries reveal that there is generally excellent healing, with scarring as a rare event. A prospective 10-year study which followed 109 children who presented with acute anogenital trauma revealed that of 35 children with tears of the posterior fourchette and/or fossa navicularis, 16 healed with vascular changes, 11 healed completely, and 2 healed with nonspecific fusion. Twelve children had hymenal abrasions or hematomas, of which 11 healed completely (one healed with slight angularity). Hymenal transections were present

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Fig. 17 Linear epidermal nevus in 1-year-old child; lesion initially mistaken for condylomata acuminata

Fig. 18 Condylomata acuminata (anogenital warts) in the perianal region of a 2-year-old child; mother noticed the warts 1 month ago, and they have been slowly enlarging since that time

in 17 children and 15 persisted. Thirteen anal abrasions and 18 perianal tears were present among the children studied. Of those injuries, all of the abrasions healed completely, and all but three of the perianal tears healed without anatomic changes. Two of the perianal tears that healed with changes were at the site of surgical repair (Heppenstall-Heger et al. 2003). A second study involved 239 females (126 pubertal, 113 prepubertal) who had hymenal injury from sexual abuse, accidental trauma, or unknown causes. The hymenal injuries healed at various rates and, except for the deeper lacerations, healed without any sign of prior trauma. Petechiae disappeared within 48 h in prepubertal females. Abrasions and mild submucosal bleeds healed within 3 to 4 days, whereas

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Fig. 19 (a) (left) [same patient as Fig. 8]. Patient is 6-year-old child with hymenal transection at 6 o’clock after report of falling from a bunk bed onto a pool cue leaning against the wall. Incident witnessed by her sister, who confirmed the history. Scene investigation revealed blood on pool cue in children’s room. (b) (right). Same patient five days later; there is significantly less tenderness of the genital region, and the defect at the base of the hymen and in the fossa navicularis is filling in

more extensive hemorrhages took 11 to 15 days to disappear. There was no scar tissue formation in prepubertal or pubertal girls (McCann et al. 2007). In general, the anogenital tissue heals rapidly and well, with little need for medical intervention. This rapid and complete healing is one of the reasons why anogenital examinations in the sexually abused child are so often normal; certainly, if an examination takes place months or years after an injury event, there is a very low likelihood that any sequela of the injury will remain (Figs. 19, 20, and 21).

Follow-Up Examinations Follow-up examinations can be a useful adjunct to the initial examination. A 5-year retrospective review of patients presenting with an acute sexual abuse/assault concern examined the effects of a follow-up examination on the patient’s assessment. The patients who met criteria for a follow-up examination (unclear examination findings; patient’s inability to cooperate with initial examination; improved ability to test for pregnancy and/or STIs; initial abnormal examination; stranger assault; or a history of genital-genital or anal-genital contact) returned for a visit an average of 1 month after their initial visit. Because 129 (17.7%) of the patients who returned for a second examination had a change in the interpretation of their examination findings. Also, 47 (6.5%) of patients had a new STI diagnosed at their second visit. When looking specifically at prepubertal patients, 49 (15.5%) had a change in interpretation of their examination findings, and 16 (5.1%) were diagnosed with a new STI during their second examination. These study findings suggest that a

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Fig. 20 (a, b) Patient is a 10-year-old female reporting penile-vaginal penetration who had multiple genital injuries, including a healed transection at 6 o’clock, a fossa navicularis abrasion, and perihymenal bruises (from 9 o’clock to 11 o’clock). (c) Patient in Fig. 19a is seen again 20 days later. Persistent hymenal defect at 6 o’clock, healing of fossa navicularis abrasion, resolution of perihymenal bruises

follow-up examination can provide additional useful information for the evaluation of the sexually abused child (Gavril et al. 2012).

Key Points • Abnormal findings diagnostic of sexual abuse are rare in a prepubertal child. • There are many dermatologic, infectious, urologic, and congenital conditions which can mimic findings due to trauma. • Accidental genital trauma can occur, but a careful history and investigation are needed to determine whether the injury is consistent with the provided history.

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Fig. 21 (a) (left). Infant with perianal abrasion of unknown cause. (b) (right). Follow-up examination 2 days later

• There are clearly defined examination abnormalities which are diagnostic of traumatic anogenital injury. • Certain sexually transmitted infections (STIs) are diagnostic, suspicious, or highly suspicious of sexual abuse and should be considered evidence of sexual abuse in the absence of perinatal transmission or other plausible explanation. • Screening urine, oropharyngeal, and rectal sites will maximize the likelihood of abnormal STI testing. • Although culture is still considered the gold standard for STI screening, many providers have begun using nucleic acid amplification tests (NAATs) due to their ease of use and high sensitivity/specificity. • Positive NAATs must be confirmed due to the possibility of false positives in prepubertal children. • Follow-up visits are recommended approximately 1 month after initial evaluation in children with acute allegations.

Summary and Conclusion Although anogenital injuries are rare among the prepubertal population, when they are found, they must be distinguished from medical conditions or accidental trauma. STI testing should be performed routinely for children who have been sexually abused, with testing at multiple sites (urine/urethral, rectum, oropharyngeal) to maximize the likelihood of finding chlamydia and gonorrhea. Screening for syphilis and HIV should be performed as needed in the prepubertal age group. The diagnosis of gonorrhea, chlamydia, syphilis, or HIV infection in a prepubertal child who is past the neonatal period is diagnostic of child sexual abuse. A diagnosis of trichomoniasis is highly suspicious for abuse. When a prepubertal child is diagnosed with herpes or condyloma, child abuse is suspected. Injuries to the anogenital region only rarely require medical intervention for hemostasis or healing and heal well. Follow-up examinations are recommended for better diagnostic accuracy.

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Cross-References ▶ Genital Examination Techniques ▶ Mimickers of Child Sexual Abuse

References Adams, J. A., Harper, K., Knudson, S., & Revilla, J. (1994). Examination findings in legally confirmed child sexual abuse: It’s normal to be normal. Pediatrics, 94, 310–317. Adams, J. A., Farst, K. J., & Kellogg, N. D. (2018). Interpretation of medical findings in suspected child sexual abuse: An update for 2018. Journal of Pediatric and Adolescent Gynecology, 31, 225–231. https://doi.org/10.1016/j.jpag.2017.12.011. American Academy of Pediatrics. (2018a). Sexually transmitted infections in adolescents and children. In D.W. Kimberlin, M. T. Brady, M. A. Jackson, & S. S. Long (Eds.), AAP red book: 2018 report of the committee on infectious diseases (31st ed., pp. 165–176). American Academy of Pediatrics. American Academy of Pediatrics. (2018b). Chlamydia trachomatis. In D. W. Kimberlin, M. T. Brady, M. A. Jackson, & S. S. Long (Eds.), AAP red book: 2018 report of the committee on infectious diseases (31st ed., pp. 276–283). Itasca: American Academy of Pediatrics. American Academy of Pediatrics. (2018c). Gonococcal infections. In D.W. Kimberlin, M. T. Brady, M. A. Jackson, & S. S. Long (Eds.), AAP red book: 2018 report of the committee on infectious diseases (31st ed., pp. 355–365). American Academy of Pediatrics. American Academy of Pediatrics. (2018d). Syphilis. In D.W. Kimberlin, M. T. Brady, M. A. Jackson, & S. S. Long (Eds.), AAP Red Book: 2018 report of the committee on infectious diseases (31st ed., pp. 773–788). American Academy of Pediatrics. American Academy of Pediatrics. (2018e). Human immunodeficiency virus infection. In D.W. Kimberlin, M. T. Brady, M. A. Jackson, & S. S. Long (Eds.), AAP red book: 2018 report of the committee on infectious diseases (31st ed., pp. 459–476). American Academy of Pediatrics. American Academy of Pediatrics. (2018f). Trichomonas vaginalis Infections. AAP Red Book: 2018 report of the committee on infectious diseases (31st ed., pp. 820–823). American Academy of Pediatrics. American Academy of Pediatrics. (2018g). Herpes simplex. In D.W. Kimberlin, M. T. Brady, M. A. Jackson, & S. S. Long (Eds.), aap red book: 2018 report of the committee on infectious diseases (31st ed., pp. 437–449). American Academy of Pediatrics. American Academy of Pediatrics. (2018h). Human papillomaviruses. In D.W. Kimberlin, M. T. Brady, M. A. Jackson, & S. S. Long (Eds.), AAP red book: 2018 report of the committee on infectious diseases (31st ed., pp. 582–590). American Academy of Pediatrics. Anderst, K., Kellogg, N., & Jung, I. (2009). Reports of repetitive penile-genital penetration often have no definitive evidence of penetration. Pediatrics, 124(3), e403–e409. https://doi.org/ 10.1542/peds.2008-3053. Casey, J. T., Bjurlin, M. A., & Cheng, E. Y. (2013). Pediatric genital injury: An analysis of the National Electronic Injury Surveillance System. Urology, 82(5), 1125–1130. https://doi.org/ 10.1016/j.urology.2013.05.042. Centers for Disease Control and Prevention. (2016). Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV – United States, 2016. US Department of Health and Human Services. De Jong, A. R., & Rose, M. (1989). Frequency and significance of physical evidence in legally proven cases of child sexual abuse. Pediatrics, 84(6), 1022–1026. Eroglu, E., Yip, M., Oktar, T., Kayiran, S. M., & Mocan, H. (2011). How should we treat prepubertal labial adhesions? Retrospective comparison of topical treatments: Estrogen only,

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betamethasone only, and combination estrogen and betamethasone. Journal of Pediatric and Adolescent Gynecology, 24(6), 389–391. Funaro, D., Lovett, A., Leroux, N., & Powell, J. (2014). A double-blind, randomized prospective study evaluating topical clobetasol propionate 0.05% versus topical tacrolimus 0.1% in patients with vulvar lichen sclerosus. Journal of the American Academy of Dermatology, 7(1), 84–91. Gabriel, N. M., Clayton, M., & Starling, S. P. (2009). Vaginal laceration as a result of blunt vehicular trauma. Journal of Pediatric and Adolescent Gynecology, 22, e166–e168. Gavril, A. R., Kellogg, N. D., & Nair, P. (2012). Value of follow-up examinations of children and adolescents evaluated for sexual abuse and assault. Pediatrics, 129(2), 282–289. https://doi.org/ 10.1542/peds.2011-0804. Goldman, R. D. (2013). Estrogen cream for labial adhesion in girls. Canadian Family Physician, 59(1), 37–38. Heger, A., Ticson, L., Velasquez, O., & Bernier, R. (2002). Children referred for possible sexual abuse: Medical findings in 2384 children. Child Abuse & Neglect, 26, 645–659. Heppenstall-Heger, A., Mcconnell, G., Ticson, L., Guerra, L., Lister, J., & Zaragoza, T. (2003). Healing patterns in anogenital injuries: A longitudinal study of injuries associated with sexual abuse, accidental injuries, or genital surgery in the preadolescent child. Pediatrics, 112(4), 829–837. https://doi.org/10.1542/peds.112.4.829. Holbrook, C., & Misra, D. (2012). Surgical management of urethral prolapse in girls: 13 years’ experience. BJU International, 110(1), 132–134. Iqbal, C. W., Jrebi, N. Y., Zielinski, M. D., Benavente-Chenhalls, L. A., Cullinane, D. C., Zietlow, S. P., Moir, C. R., & Ishitani, M. B. (2010). Patterns of accidental genital trauma in young girls and indications for operative management. Journal of Pediatric Surgery, 45(5), 930–933. Jenny, C., Crawford-Jakubiak, J. E., & Committee on Child Abuse and Neglect. (2013). The evaluation of children in the primary care setting when sexual abuse is suspected. Pediatrics, 132, e558–e567. Kellogg, N., & the Committee on Child Abuse and Neglect. (2005). The evaluation of sexual abuse in children. Pediatrics, 116(2), 506–512. Kellogg, N. D., Menard, S. W., & Santos, A. (2004). Genital anatomy in pregnant adolescents: “Normal” does not mean “nothing happened”. Pediatrics, 113(1), e67–e69. Kellogg, N., Melville, J., Lukefahr, J., Nienow, S., & Russell, E. (2018). Genital and extragenital gonorrhea and chlamydia in children and adolescents evaluated for sexual abuse. Pediatric Emergency Care, 34(11), 761–766. Marfatia, Y., Surani, A., & Baxi, R. (2019). Genital lichen sclerosus et atrophicus in females: An update. Indian Journal of Sexually Transmitted Diseases and AIDS, 40(1), 6–12. McCann, J., Miyamoto, S., Boyle, C., & Rogers, K. (2007). The healing of hymenal injuries in prepubertal and adolescent females: A descriptive study. Pediatrics, 119(5), e1094–e1106. https://doi.org/10.1542/peds.2006-0964. Miller, J. M., Binnicker, M. J., Campbell, S., Carroll, K. C., Chapin, K. C., Gilligan, P. H., Gonzalez, M. D., Jerris, R. C., Kehl, S. C., Patel, R., Pritt, B. S., Richter, S. S., RobinsonDunn, B., Schwartzman, J. D., Snyder, J. W., Telford, S., III, Theel, E. S., Thomson, R. B., Jr., Weinstein, M. P., & Yao, J. D. (2018). A guide to the utilization of the microbiology laboratory for diagnosis of infectious diseases: 2018 update by the Infectious Diseases Society of America and the American Society for Microbiology. Clinical Infectious Diseases, 67(6), e1–e94. Powell, J., & Wojnarowska, F. (2001). Childhood vulvar lichen sclerosus: An increasingly common problem. Journal of the American Academy of Dermatology, 44(5), 803–806. Scheidler, M. G., Schultz, B. L., Schall, L., & Ford, H. R. (2000). Mechanisms of blunt perineal injury in female pediatric patients. Journal of Pediatric Surgery, 35(9), 1317–1319. Sena, A. C., Hsu, K. K., Kellogg, N., Girardet, R., Christian, C. W., Linden, J., Griffith, W., Marchant, A., Jenny, C., & Hammerschlag, M. R. (2015). Sexual assault and sexually transmitted infections in adults, adolescents, and children. Clinical Infectious Diseases, 61(S8), S856–S864. Smith, T. D., Raman, S. R., Madigan, S., Waldman, J., & Shouldice, M. (2018). Anogenital findings in 3569 pediatric examinations for sexual abuse/assault. Journal of Pediatric and Adolescent Gynecology, 31(2), 79–83. https://doi.org/10.1016/j.jpag.2017.10.006.

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Spitzer, R. F., Kives, S., Caccia, N., Ornstein, M., Goia, C., & Allen, L. M. (2008). Retrospective review of unintentional female genital trauma at a pediatric referral center. Pediatric Emergency Care, 24(12), 831–835. Uprety, P., & Cardenas, A. M. (2019). Extragenital screening is essential for comprehensive detection of Chlamydia trachomatis and Neisseria gonorrhoeae in the pediatric population. Journal of Clinical Microbiology, 57(6), e00335–e00319. https://doi.org/10.1128/JCM.00335-19. Widni, E. E., Hollwarth, M. E., & Saxena, A. K. (2011). Analysis of nonsexual injuries of the male genitals in children and adolescents. Acta Paediatrica, 100(4), 590–593. Workowski, K. A., Bolan, G. A., & Center for Disease Control. (2015). Sexually transmitted diseases treatment guidelines. Morbidity and Mortality Weekly Reports Recommendations and Reports, 64(3), 1–137.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomic Variants and Congenital Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Normal Anogenital Anatomy and Physiologic Processes Mistaken for Sexual Abuse Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Congenital Malformations Mimicking Sexual Abuse Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dermatoses and Anogenital Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anogenital Irritant Contact Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anogenital Allergic Contact Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vulvar Atopic Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lichen Sclerosus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anogenital Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vaginal Discharge and Foreign Bodies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anogenital Infections not Caused by Sexual Contact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anogenital Infections Caused by Both Sexual and Nonsexual Contact . . . . . . . . . . . . . . . . . . . Medical Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical Conditions Resulting in Displacement of Normal Anatomic Structures . . . . . . . . . Nonabusive Vesicular and Ulcerative Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gynecologic Neoplasias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vascular and Lymphatic Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hidradenitis suppurativa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Enuresis and Encopresis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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J. Ingalls (*) Child Abuse Referral and Evaluation (CARE) Clinic, Sanford Children’s Hospital Fargo, Sanford Health, Fargo, ND, USA e-mail: [email protected] N. S. Harper Pediatric Emergency Medicine and Child Abuse, University of Minnesota, Minneapolis, MN, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_244

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Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Accidental Anogenital Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical Conditions Resulting in Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physical Abuse of the Genitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

This chapter examines conditions commonly mistaken for child sexual abuse because they mimic acute genital trauma, residua of prior genital trauma, or sexually transmitted infections (STIs) due to sexual assault and/or abuse. Expanding upon the foundation laid in the previous chapter on normal anogenital anatomy, this chapter discusses anatomical variants and physiologic processes that are commonly mistaken for acute or chronic findings of sexual assault. Dermatoses and infections that are frequently mistaken for acute sexual assault injuries and STIs will also be explored. Additionally, this chapter reviews medical conditions unrelated to sexual assault which result in anogenital bleeding or ulcers that mimic signs of acute sexual assault or STIs. Additionally, causes of anogenital trauma not due to sexual assault are discussed.t Keywords

Behçet’s disease · Failure of midline fusion · Fossa groove · Labial adhesions · Lichen sclerosus · Neonatal menstruation · Perianal pseudoverrucous papules and nodules (PPPN) · Perirectal strep · Straddle injury · Urethral prolapse

Introduction Medical providers routinely perform anogenital examinations as part of well child checks and when specific anogenital complaints are reported by patients or their caregiver(s). Thus, medical providers need to be knowledgeable about normal anogenital anatomy, examination findings concerning for sexual abuse, and clinical signs of sexually transmitted infections (STIs). Additionally, medical providers need to be well-versed in conditions that may be mistaken for sexual assault and/or abuse to avoid misdiagnosis and undue stress for the patient and family. With increased evidencebased research on the interpretation of anogenital findings in children and adolescents, the consensus on medical findings that may be confused for sexual abuse has increased. A true mimic of a finding due to sexual assault/abuse either mimics acute anogenital trauma, the residua of injury from the acute trauma, or the signs and symptoms of STIs. These so-called mimickers of child sexual abuse range from the very common complaint of genital redness to uncommon complaints such as ulcerative lesions. This chapter reviews many of the more common mimickers of child sexual abuse including anatomical variants and conditions, dermatoses, known medical conditions, nonsexually transmitted anogenital infections, and nonabusive anogenital trauma.

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Anatomic Variants and Congenital Conditions Some of the most common referrals to tertiary care centers for sexual abuse medical evaluations result from a lack of recognition of normal genital pediatric anatomy, especially female genitalia, and normal anogenital physiology. Additionally, congenital malformations of the anogenital structures may be mistaken for injuries resulting from sexual assault. This section will briefly review a few normal anatomic variants, physiologic processes, and congenital malformations that are commonly mistaken for sexual assault injuries. For more detailed information, please see ▶ Chap. 41, “Normal Examination Findings and Variants.”

Normal Anogenital Anatomy and Physiologic Processes Mistaken for Sexual Abuse Injuries Normal Anogenital Anatomy Mistaken for Genital Injury Normal Anogenital Hyperpigmentation Normal pigment for the skin and mucosa of anogenital structures ranges from pink to dark brown. In individuals with lighter skin coloring, the skin and mucosa of their genital structures is pink in color; whereas for individuals with more melanin, the skin and mucosa of their anogenital structures ranges from pink to gray or dark brown. Medical providers and caretakers who are unfamiliar with normal anogenital pigmentation may mistake normal hyperpigmentation of the labia minora and perianal region for genital and anal bruising due to sexual abuse. However, darker pigmentation of the labia minora and perianal areas in individuals with darker skin pigmentation is considered a normal variant unrelated to sexual abuse (Adams et al. 2018) (Figs. 1 and 2) (McCann et al. 1989).

Fig. 1 An 8-month-old female referred from a pediatric clinic for an acute sexual assault examination due to an incidental finding of “genital bruising” with no caretaker concern for sexual abuse. The “genital bruising” is actually normal hyperpigmented labia minora for her skin complexion

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Fig. 2 Normal perianal hyperpigmentation in a child with a darker skin complexion

Fig. 3 A fossa groove in a 14-year-old female

Normal Midline Variants A few normal midline variants that can be mistaken for subacute or permanent injuries, particularly scars, from sexual abuse include fossa navicularis grooves, linea vestibularis, median perineal raphe, diastasis ani, and perianal skin tags. A fossa navicularis groove (fossa groove) is a shallow depression in the mucous membrane of the posterior to mid portions of the midline fossa navicularis (Fig. 3). The margins of fossa grooves may have flesh-colored protrusions, which are normal vestibular papillae. Due to their clinical appearance, fossa grooves have been mistaken for scars from healed injuries obtained during sexual assault, but they are normal midline genital variants seen only in females (Adams et al. 2018). There are

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limited data on the prevalence and natural history of fossa grooves, but they have been reported to occur in at least 25% of females (Myhre et al. 2010). Fossa grooves are most commonly seen in early pubertal females and may self-resolve in later stages of pubertal development. Linea vestibularis is an avascular, pale or white, vertically-oriented, linear area of mucosa extending from the base of the hymen through the fossa navicularis to the posterior fourchette. Partial linea vestibularis may also occur anywhere along this region. Linea vestibularis is considered a normal variant of the midline female genitalia (Adams et al. 2018; Berenson et al. 2000). Linea vestibularis is found in 19% of prepubertal females (Heger et al. 2002) without a history of sexual abuse. Linea vestibularis may be mistaken for a scar from sexual assault due to its appearance and location. Median raphe is a midline ridge of anogenital tissue that may have increased pigmentation. This finding can be seen in males and females. In males, a prominent median raphe may extend from the midline dorsum of the penis, along the scrotum, and across the perineum to the anus. In females, a prominent median raphe may extend from the posterior commissure to the anus. Medical providers have mistaken a prominent median raphe for a scar due to sexual assault, when it is actually a normal anatomic variant (Adams et al. 2018). Perianal skin tags are benign growths of excess skin around the anus (Fig. 4). Many caretakers and medical providers who find a perianal skin tag on a child interpret it as an abnormal finding caused by anal penetration during sexual assault. However, perianal skin tags are generally considered a normal variant, not the residua of sexual abuse (Adams et al. 2018). Perianal skin tags are found equally in sexually abused children with and without disclosures of or witnessed anal penetration (Myhre et al. 2013), so the presence of perianal skin tags cannot be used to identify children who have been anally penetrated. Perianal skin tags can be a remnant of resolved anal fissures or hemorrhoids not caused by sexual abuse, which are discussed later. Fig. 4 A large perianal skin tag at 12 o’clock to 1 o’clock

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Normal Anogenital Physiology Mistaken for Injury from Trauma Neonatal Menstruation During pregnancy, maternal progesterone crosses the placenta and the fetus is exposed to its effects. When maternal progesterone is no longer passed to the neonate after birth, the female neonate can develop progesterone withdrawal resulting in neonatal menstruation, also referred to as neonatal uterine bleeding. Neonatal menstruation is generally considered a benign physiologic process; however, new parents and medical providers who are unfamiliar with this process may mistake it as a sign of genital trauma from sexual assault. Perianal Venous Congestion Perianal venous congestion or pooling is a change in the color of the perianal skin to blue or purple due to obstruction of the external rectal venous plexus, resulting in engorgement of the vessels with deoxygenated blood (Fig. 5). Perianal venous congestion is a normal physiologic process that occurs with maintaining certain positions for a prolonged period of time, such as the supine knee-chest position used for most child sexual abuse medical examinations. Perianal venous congestion occurs in over 50% of nonabused children after being in the knee-chest position for just 2 min (McCann et al. 1989). Medical providers who are unaware of perianal venous congestion have mistaken the perianal color change for bruising from sexual assault, when it is a normal physiologic process (Adams et al. 2018). To distinguish perianal venous congestion from perianal bruising, the medical provider should have the child stand and walk around for several minutes and then re-examine the anus. Perianal venous congestion will resolve with a change in position, whereas perianal bruising will remain unchanged. Anal Dilatation Anal dilatation in the context of sexual abuse is a complex topic, and its interpretation depends on the type of anal dilatation and the presence or absence of causative underlying medical conditions or medications. Partial or external anal dilatation Fig. 5 Perianal venous congestion, partial anal dilatation, and visualization of the pectinate line in an infant undergoing a prolonged supine anogenital exam. (Photo courtesy of Dena Naser, MD at Wayne State University Kids TALK Medical Clinic in Detroit, Michigan)

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Fig. 6 (a) Anal dilatation due to sedation in a patient with anal fissures. (b) Anal dilation due to stool in the anal canal

occurs when the external anal sphincter dilates, but the internal anal sphincter remains closed. Partial anal dilatation may allow visualization of the pectinate line (see Fig. 5 and Fig. 18b) and anal canal mucosa, which medical providers may mistake for anal lacerations from anal penetration when in fact it is normal tissue. Partial anal dilatation with or without visualization of the pectinate line and anal mucosa is considered normal (Adams et al. 2018). Complete or total anal dilatation occurs when both the internal and external anal sphincters dilate (Fig. 6). Complete anal dilation can be caused by medications and underlying medical conditions not related to sexual abuse, but have also been associated with sexual abuse (Myhre et al. 2013). Medications that can cause complete anal dilatation through neuromuscular relaxation are commonly used during sedation and anesthesia. Medical conditions that can elicit complete anal dilatation include constipation, encopresis, and neuromuscular disorders causing decreased tone. Complete anal dilatation with no causative medications or medical conditions is concerning for the possibility of sexual abuse, but there is currently no expert consensus on the interpretation of this finding (Adams et al. 2018).

Congenital Malformations Mimicking Sexual Abuse Injuries Extravesicular Ureterocele An extravesicular or ectopic ureterocele is a cystic dilation of the distal ureter prolapsing through the bladder neck or urethral meatus. On physical examination a prolapsing extravesicular ureterocele presents as a circular or oval, red to purple cystic mass obstructing the view of the urethra and/or all of the genital structures deep to the labia majora in females, depending on the size of the ureterocele. Extravesicular ureteroceles are congenital malformations and are most often diagnosed in children less than 2 years of age. Ureteroceles more commonly affect females than males. A prolapsing extravesicular ureterocele mimics trauma from

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sexual assault because of the similarity between its red to purple appearance and that of an ecchymosis or submucosal hemorrhage. A prolapsing extravesicular ureterocele may also mimic another medical condition unrelated to sexual assault/ abuse but that has been mistaken by medical providers for injury from sexual assault, which is a urethral prolapse (see the “Medical Conditions” section later in this chapter for more detail). A prolapsing extravesicular ureterocele can be distinguished from a prolapsed urethra by the absence of a central depression, which is present in urethral prolapse. Extravesicular ureteroceles are associated with duplicated urinary systems and may cause bladder outlet obstruction, vesicular ureteral reflux, recurrent urinary tract infections, and kidney injury. Extravesicular ureteroceles should be referred to urology for further evaluation and treatment, which may be surgical (Chowdhary et al. 2017).

Failure of Midline Fusion Failure of Midline Fusion, also known as a perineal groove, is a rare congenital malformation consisting of an exposed, erythematous, non-epithelialized mucus membrane sulcus extending from the posterior vaginal fourchette to the anterior ridge of the anus (Fig. 7). Partial defects may occur anywhere along this region. The pathogenesis is unclear and several theories exist, including failure of the perineal raphe to fuse or a defect in the development of the embryonic cloaca or uroanal septum. In failure of midline fusion, the anogenital structures are usually otherwise normal, but failure of midline fusion may be associated with other congenital anomalies. There are limited data on the prevalence of failure of midline fusion, but it has been reported to occur in 0.6% of nonsexually abused prepubertal females (Heger et al. 2002). Failure of midline fusion may spontaneously resolve in puberty, but treatment is not usually indicated even if it does not resolve. Failure of midline fusion can be distinguished from trauma with a follow-up examination in 1 to 2 weeks at which time traumatic injuries would be partially or completed healed, whereas failure of midline fusion would not change in appearance. Diastasis Ani Diastasis ani is a congenital malformation consisting of the absence of the corrugator external anal sphincter muscle at 12 or 6 o’clock causing a loss of the normal anal skin folds (Fig. 8). The result is a smooth, roughly triangular-shaped area of skin at the 12 o’clock and/or 6 o’clock position of the anus which may or may not be depressed. Diastasis ani has been reported in up to 26% of nonabused children (McCann et al. 1989). Diastasis ani has been mistaken for anal scaring from sexual abuse, but it is now a well-recognized normal anatomic variant (Adams et al. 2018).

Dermatoses and Anogenital Discharge One of the other most frequent reasons children are referred for sexual abuse medical evaluations is a caretaker changes or bathes a child and notices that the child’s genitals or perianal area is “red,” which the caretaker thinks is due to sexual abuse.

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Fig. 7 Failure of midline fusion in a female infant. (Photo courtesy of Dena Naser, MD at Wayne State University Kids TALK Medical Clinic in Detroit, MI, USA)

Fig. 8 A 2-year-old female with diastasis ani at 12 o’clock

Additionally, some children with anogenital erythema also present with anogenital pruritus and/or vaginal discharge, heightening the caretaker’s concern for sexual abuse. In females, genital erythema and itching are referred to as vaginitis, vulvitis, or vulvovaginitis depending on the location of the symptoms, but many medical providers use these terms interchangeably. Although it is thought that anogenital erythema can occur from friction during sexual abuse, anogenital erythema and pruritus are common and nonspecific findings that are most often the result of nonabusive causes of anogenital inflammation. Anogenital discharge can be more

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concerning for sexual abuse and should prompt the medical provider to ask additional history and visualize the discharge on physical examination. However, both STIs from sexual abuse and nonabusive causes of vaginal discharge should be considered in the differential diagnosis. This section discusses several of the most common nonabusive causes of anogenital erythema, pruritus, and discharge, as well as specific dermatoses that can mimic anogenital injuries and/or STIs from sexual abuse.

Anogenital Irritant Contact Dermatitis The most common cause of anogenital erythema and pruritus is irritant contact dermatitis, which is inflammation of the skin and mucosa due to prolonged, direct contact with an irritating substance (Fig. 9). Substances that routinely cause irritant contact dermatitis in children include soaps, bubble baths, urine, and stool. Prolonged contact with urine or stool often results from poor hygiene practices such as insufficient frequency of diaper changes, inadequate wiping, and/or infrequent washing of the anogenital area. Irritant contact dermatitis can also be caused by females wiping back-to-front after stooling and children touching their anogenital region while having irritating substances on their hands. In prepubertal females, irritant contact dermatitis from poor hygiene can cause labial adhesions, which can bleed when accidentally lysed and thus mimic trauma from sexual assault. (See the “Lysed Labial Adhesions” section of the “Trauma” section later in this chapter for more details.) The treatment of irritant contact dermatitis is avoidance of contact with the causative substance.

Diaper Dermatitis, Granuloma Gluteale Infantum, Jacquet Erosive Diaper Dermatitis, and Perianal Pseudoverrucous Papules and Nodules Diaper dermatitis is a subtype of irritant contact dermatitis created by contact of the skin with substances contained by the diaper such as urine and stool. When a dirty diaper is in close contact with the skin, it produces a moist environment and friction causing disruption of skin integrity. Diaper dermatitis may be distinguished from other dermatoses by the location of the affected skin as diaper dermatitis only affects Fig. 9 Generalized vulvar erythema and hypervascularity from irritant contact dermatitis in a prepubertal female

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the skin covered by the diaper, whereas other dermatoses may also occur in extragenital sites. The best prevention for diaper dermatitis is frequent diaper changes with thorough skin cleaning and drying. Diaper dermatitis may also be prevented with the application of barrier creams such as zinc oxide or petroleum jelly. Although exceedingly rare, chronic diaper dermatitis may result in one of three erosive papulonodular dermatoses, which are granuloma gluteale infantum, Jacquet erosive diaper dermatitis, and perianal pseudoverrucous papules and nodules (PPPN). Granuloma gluteale infantum typically presents around 2 to 9 months of age as a diaper dermatitis followed by multiple inflammatory and granulomatous-like, firm, red, purple, or brown papules and nodules in the anogenital regions covered by a diaper. Jacquet erosive diaper dermatitis presents as well-demarcated, elevated papules and nodules with either central umbilication, ulcers, or erosions in the anogenital area (Fig. 10a). PPPN present as multiple pink, red, brown, white, or gray papules in the anogenital region (Fig. 10b). All three of these conditions result from chronic exposure of the affected skin to moist environments with friction and are thus more common in children with urinary or fecal incontinence or chronic diarrhea due to an underlying long-term medical condition. These three conditions were previously thought to be separate, distinct pathologies, but they share histological findings and are now regarded as a spectrum of the same condition (Robson et al. 2006).

Anogenital Allergic Contact Dermatitis Anogenital allergic contact dermatitis is far less common than irritant contact dermatitis in children, but both present with the same symptoms of anogenital erythema and pruritus. Allergic contact dermatitis is a type IV delayed hypersensitivity reaction in which the child becomes sensitized to a substance, and later reexposure causes the substance to act as an antigen which induces an immune response. Allergic contact dermatitis and irritant contact dermatitis can be distinguished by the time between contact and the onset of symptoms. Irritant contact

Fig. 10 (a) A prepubertal female with Jacquet erosive diaper dermatitis versus PPPN due to chronic enuresis who presented for blood in her underwear. (b) A 6-year-old female with PPPN from chronic encopresis

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dermatitis occurs within minutes to a few hours of contact, whereas allergic contact dermatitis generally takes 24 to 48 hours to develop. Allergic contact dermatitis of the anogenital region can result from the application of topical medications and contact with substances in over-the-counter products such diapers, wipes, dyes, and perfumes. Allergic contact dermatitis can usually be diagnosed and distinguished from similar pathologies through history and physical examination, but in rare cases a biopsy may be helpful. Once allergic contact dermatitis is diagnosed, the causative allergens can sometimes be identified by a patch test performed by a dermatologist. If an allergenic substance is identified, allergic contact dermatitis is treated by avoidance of the identified allergen.

Vulvar Atopic Dermatitis Atopic dermatitis, also known as eczema, is a chronic, inflammatory skin disease with a relapsing–remitting course that presents with intensely pruritic, erythematous skin lesions. Atopic dermatitis can present anywhere on the body, including the vulva, which is termed vulvar atopic dermatitis. Atopic dermatitis is thought to be caused by a combination of genetic predisposition and environmental conditions, such as exposure to cold weather and irritating substances, which disrupt the barrier function of the skin. Many patients with atopic dermatitis have a personal or family history of atopy. The appearance of atopic dermatitis lesions changes over time with acute atopic dermatitis presenting as poorly demarcated, erythematous plaques with peripheral scales. In chronic atopic dermatitis, these lesions become thickened, lichenified plaques. Due to the pruritus, children with atopic dermatitis may scratch their genitals resulting in excoriations that mimic acute trauma from sexual assault. Repetitive scratching of the affected genitalia may result in postinflammatory hypo- or hyper-pigmentation that may be mistaken for scars from healed trauma. Atopic dermatitis is clinically diagnosed by history and physical examination, but in rare circumstances a biopsy may be indicated. Atopic dermatitis is incurable, so the goal of treatment is disease control with avoidance of irritant and allergenic substances. Active atopic dermatitis is treated with topical corticosteroids for inflammation, H1-antihistamines for pruritus, and petroleum jelly, dimethicone cream, or zinc oxide cream as a skin barrier.

Lichen Sclerosus Lichen sclerosus is a chronic, inflammatory cutaneous disease that predominantly presents in the anogenital region, but rarely may occur elsewhere on the body. Lichen sclerosus has also been referred to as leukoplakia, kraurosis vulvae, balanitis xerotica, and lichen sclerosus et atrophicus. Lichen sclerosus can present in either gender at any age, but the average age of the onset of symptoms for females is 5 years. The estimated prevalence of lichen sclerosus is 1 in 900 for prepubertal

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Fig. 11 A prepubertal female with ecchymoses and abrasions to her labia majora, labia minora, and posterior fourchette which were initially mistaken for acute genital trauma from sexual assault. The child was diagnosed with lichen sclerosus and self-induced her genital injuries by scratching the affected skin. (Photo courtesy of Sonja Eddleman, MSN, RN, SANE-A, SANE-P, CARE team clinical coordinator at Driscoll Children’s Hospital in Corpus Christi, TX, USA)

females (Powell and Wojnarowska 2001). The exact pathogenesis of lichen sclerosus remains unknown, but it is considered an autoimmune disorder with many patients having a personal or family history of other autoimmune diseases. Lichen sclerosus commonly presents as genital bruising and bleeding, which is mistaken for trauma from sexual assault (Bercaw-Pratt et al. 2014; Powell and Wojnarowska 2001). The initial presentation of lichen sclerosus is an asymptomatic, thin, atrophic, white plaque, most classically in a figure-of-eight shape around the labia majora and anus, which often goes unnoticed until it becomes pruritic (BercawPratt et al. 2014). When the child scratches the affected anogenital skin, it may result in ecchymoses, purpura, fissures, and bleeding which mimics the findings of acute trauma from sexual assault (Bercaw-Pratt et al. 2014; Powell and Wojnarowska 2001) (Fig. 11). One way to differentiate lichen sclerosus from acute trauma due to sexual assault is that lichen sclerosus only affects the epidermis, not the mucosa; whereas, acute trauma from sexual assault often involves the vulvar mucosa (Bercaw-Pratt et al. 2014). Furthermore, the distribution of affected skin in lichen sclerosus is typically symmetric, whereas trauma from sexual assault is usually asymmetric. Lichen sclerosus is treated with high potency topical corticosteroids in addition to antihistamines and emollients for the pruritus. Lichen sclerosus can result in labial and clitoral hood adhesions and anogenital scarring. Lichen sclerosus carries a high recurrence rate in prepubertal females and may not resolve with puberty as previously thought (Powell and Wojnarowska 2001). Post-menopausal women with lichen sclerosus are at increased risk of developing vulvar cancers, but it is unclear whether this risk exists in children and adolescents.

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Anogenital Psoriasis Psoriasis is a chronic, immune-mediated, inflammatory skin disease with a remittingrelapsing course whose exact etiology remains uncertain, but genetic predisposition and environmental factors are thought to be causative. Up to 71% of pediatric patients with psoriasis have a first-degree relative with the disease (Morris et al. 2001). Known environmental triggers for new-onset and exacerbation of psoriasis include upper respiratory viral infections and bacterial infections, especially pharyngeal group A streptococcus (GAS) (Seyhan et al. 2006). In the United States (US), the estimated prevalence of pediatric psoriasis is less than 1%, it occurs equally in both genders, and the median age at diagnosis is 11 years (Tollefson et al. 2010). Patients with psoriasis have a wide range of presentations and severities with subtypes of psoriasis including plaque, flexural, and guttate. The most common sites of psoriasis in older children are the extremities, trunk, and scalp where the lesions are well-defined, erythematous, pruritic plaques with silver scales. In contrast, in children under 2 years of age, psoriasis usually presents with only anogenital involvement with symmetric, large, well-demarcated areas of confluent pink to red plaques without scales (Eichenfield et al. 2018; Morris et al. 2001; Tollefson et al. 2010). Anogenital psoriasis is often misdiagnosed as irritant contact diaper dermatitis, atopic dermatitis, or other dermatoses or infections, resulting in delayed diagnosis. Additionally, children may scratch pruritic anogenital psoriatic lesions, causing excoriations mimicking injuries seen in acute sexual assault. Psoriasis is an incurable disease and treatment is therefore aimed at symptom control and eradication of triggers. If skin or pharyngeal bacterial infections are contributing to psoriasis, cultures should be obtained and antibiotic treatment provided. Psoriasis is primarily treated with topical corticosteroids, but topical calcineurin inhibitors, phototherapy, etanercept, and other systemic medications may be used in severe cases.

Vaginal Discharge and Foreign Bodies Vaginal discharge in pubertal females has a large differential including physiologic leukorrhea, nonabuse-related genital infections such as candidiasis, retained foreign bodies such as tampons and infected contraceptive devices, and STIs from either consensual sexual contact or sexual abuse/assault. A thorough history and anogenital examination will help guide the workup of vaginal discharge in this population. In the prepubertal female, the most common cause of vaginal discharge is vulvovaginitis unrelated to sexual abuse (McGreal and Wood 2013). Vaginal discharge in prepubertal females can be caused by a host of nonsexually transmitted genital infections. (Please see the “Infections” section later in the chapter for

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Fig. 12 A vaginal foreign body in a 7-year-old female who repeatedly put toilet paper in her vagina after being sexually abused

more details.) Many of the nonabuse-related bacterial genital infections cause a malodorous vaginal discharge, so the presence or absence of a nonspecific odor cannot be used to distinguish vaginal discharges due to STIs. The majority of prepubertal females will have resolution of their vaginal discharge with simple changes in hygiene practices, the use of emollients to provide a barrier to the skin, and less commonly, the use of specific antibiotics to treat certain nonabusive anogenital infections. Vaginal discharge in prepubertal females that is resistant to the aforementioned treatments, or is purulent or bloody, requires further workup with consideration of sexual abuse, STIs, genital neoplasms, and retained vaginal foreign bodies as the cause. Some vaginal foreign bodies occur accidentally through routine wiping and bathing and are not concerning for sexual abuse. Although a young female inserting an object into the genitalia can be concerning for a sexualized behavior due to sexual abuse (Fig. 12), it can also be age-appropriate, normal sexual behavior when a child first discovers a new body cavity (Friedrich et al. 1998). Common vaginal foreign bodies include pieces of toilet paper, bath sponges, or coins (McGreal and Wood 2013), but other objects are possible. Retained foreign bodies in the vagina are difficult to see on visual inspection, thus patients with suspected vaginal foreign bodies may require sedated vaginoscopy for inspection and removal.

Infections Another common cause of anogenital erythema, pruritus, and/or genital discharge in children that may raise caretaker concern for sexual abuse are anogenital infections. Although many organisms which infect the anogenital tracts of children are not associated with sexual abuse, there are several organisms that can be transmitted by both abusive and nonabusive mechanisms. A full discussion of STIs is beyond the scope of this chapter; however, this section will briefly cover

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several of the more common nonabusive and possibly abusive anogenital infections.

Anogenital Infections not Caused by Sexual Contact The normal vaginal microbiome of prepubertal females has been studied, but the frequency of the various normal microorganisms present varies amongst studies (Gardner 1992; Hammerschlag et al. 1978). The normal vaginal microbiome of prepubertal females differs from that of pubertal females based on the effect of estrogen, which makes the pubertal vagina more acidic. The more alkaline vaginal pH in prepubertal females results in this population being more likely to have non-abuse related, bacterial genital infections and less likely to have candidal genital infections. Candidal genital infections in prepubertal females usually only occur in diabetics, immunosuppressed patients, and those prescribed oral antibiotics. Conversely, Candida albicans genital infections are common in pubertal females. However, candidal genital infections in either pubertal or prepubertal females are not concerning for sexual abuse (Adams et al. 2018). Studies of the bacterial species causing vulvovaginitis in prepubertal females vary by species and prevalence. However, multiple studies have shown that the most common bacteria causing vulvovaginitis in prepubertal females include diptheroids, group A beta hemolytic Streptococcus (GAS), group B hemolytic Streptococcus (GBS), Streptococcus milleri, Enterococcus faecalis, Staphylococcus aureus, Haemophilus influenzae, Escherichia coli, Klebsiella species, Proteus species, Pseudomonas species, Shigella species, other gram negative enterics, and anaerobes (Adams et al. 2018; Hammerschlag et al. 1978; McGreal and Wood 2013; Yilmaz et al. 2012). In addition to the aforementioned bacterial species, pubertal females may also develop vulvovaginitis due to infection by Enterobacter cloacae and Ureaplasma (Yilmaz et al. 2012). All of the above listed bacteria may result in a non-specific vaginal discharge, but Shigella is unique in that it may produce a bloody vaginal discharge (Gryngarten et al. 1994). Vulvovaginitis from any of the bacterial species listed above is considered to be unrelated to sexual abuse (Adams et al. 2018). Of the identified species above, anogenital infection by group A beta hemolytic Streptococcus (GAS) is particularly prone to being mistaken for trauma from sexual abuse due to the intense vulvar and/or perianal erythema it produces, often described as “beefy red.” GAS most commonly infects the perianal skin, referred to as perianal strep, but may also infect the perineal and vulvar skin. Anogenital GAS infection most commonly presents with anogenital pruritus, but anogenital pain, dysuria, and anal bleeding from fissures may also occur. Anogenital GAS infection is often diagnosed clinically, but before initiating treatment, confirmation should be made with a genital streptococcal culture. Anogenital GAS is treated with oral antibiotics, most commonly penicillin.

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Anogenital Infections Caused by Both Sexual and Nonsexual Contact Molluscum Contagiosum Molluscum contagiosum is a temporary, self-limited, infectious dermatosis of the skin that is most commonly seen in young children but may also occur in sexually active adolescents and adults. Molluscum contagiosum is caused by the virus Molluscum contagiosum, which is transmitted by direct skin-to-skin contact through sexual and non-sexual means, including autoinoculation. Molluscum contagiosum presents as multiple, firm, shiny, white or skin-colored papules with central umbilication anywhere on the body. Molluscum contagiosum papules typically initially present on the trunk and extremities in children, and are spread to the anogenital region through autoinoculation by the child touching the non-anogenital papules and then touching the anogenital area. Children presenting with anogenital molluscum contagiosum should have a thorough skin examination to evaluate for papules elsewhere on the body. The diagnosis of molluscum contagiosum is primarily clinical due to the classic appearance of the umbilicated papules. Treatment of molluscum contagiosum is controversial since it is a disorder which spontaneously resolves within several months to a few years. However, if the papules are extensive, cause complications, or the patient has aesthetic concerns, treatment can be completed through a variety of therapies including mechanical curettage, cryotherapy, application of cantharidin, immunomodulatory medications, and antiviral medications. Condyloma Acuminatum Genital warts, also known as condyloma acuminatum, are caused by infection with several serotypes of human papillomavirus (HPV) including 6, 11, 16, and 18 among others (Fig. 13). HPV can be transmitted sexually and non-sexually, including through horizontal transmission (e.g., auto-inoculation or fomite) and vertical transmission. Vertical transmission from an infected mother to her neonate can occur through both transplacental and perinatal mechanisms. Since HPV can be transmitted sexually in children of any age, a medical evaluation for sexual abuse, including testing for other sexually transmitted infections, may be indicated in any child with condyloma acuminatum with concerns of abuse. However, children under 5 years of Fig. 13 Perianal condyloma acuminata in a 4-year-old female with no history of sexual abuse

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age are more likely than older children to have condyloma acuminatum due to vertical transmission (Adams et al. 2018). A history of HPV infection and/or genital warts in caretakers(s), sibling(s), and other close contacts should be obtained. Condyloma acuminata are generally diagnosed by their clinical appearance and self-resolve with time. However, referral to dermatology for treatment may be indicated if the warts are extensive or if there are complications.

Scabies Scabies is an infestation of the skin caused by the mite Sarcoptes scabiei. Scabies typically presents with severe pruritus of the affected skin, which is most commonly the webbing of the fingers and flexural surfaces of the perineum, gluteal cleft, axillae, elbows, and wrists. On physical exam, scabies appears as skin burrows, papules, and/or pustules on the affected skin, which when present in the anogenital area can raise concern for transmission through sexual abuse. Although scabies can be transmitted by direct contact with infected skin during sexual abuse, scabies is more commonly transmitted by nonsexual direct contact in crowded living conditions or by autoinoculation. Patients with scabies and all of their close contacts should be treated with 5% permethrin cream to eliminate both the living mites and their eggs.

Medical Conditions Many medical conditions unrelated to sexual abuse can present with anogenital involvement that may be mistaken for injuries or STIs acquired through sexual assault. Since anogenital injuries from sexual abuse are rare in children (please see ▶ Chap. 40, “Genital Examination Techniques”), other medical conditions with anogenital involvement must be kept in mind. This section reviews medical conditions that may mimic sexual abuse findings including those resulting in displacement of normal anatomic structures, nonabusive vesicular and ulcerative conditions, neoplasias, vascular and lymphatic malformations, and hidradenitis suppurativa. Additionally, medical conditions that are seen both in abused and nonabused children, such as enuresis and encopresis, are also briefly discussed.

Medical Conditions Resulting in Displacement of Normal Anatomic Structures There are a few medical conditions that cause displacement of normal anatomic structures, which may mimic trauma from acute sexual assault. Such medical conditions include urethral prolapse, hemorrhoids, and rectal prolapse.

Urethral Prolapse Urethral prolapse occurs when the urothelium lining the urethra everts through the urethral meatus (Fig. 14). Urethral prolapse typically presents as painless blood in the underwear or on toilet paper. On physical exam, urethral prolapse appears as an

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Fig. 14 A 7-year-old female with a mild urethral prolapse

edematous, red or purple ring of tissue with a central depression that is painful to palpation. The bleeding and/or pain with palpation caused by urethral prolapse can be confused with genital trauma, especially when the prolapse is large enough to obstruct the view of the hymen. To confirm a urethral prolapse and visualize the hymen, gentle inferior pressure may be applied with a gloved finger on the posterior fourchette or a small swab may be used lift the inferior outer surface of urethral prolapse superiorly. The etiology of urethral prolapse is not well understood but is thought to be due primarily to estrogen deficiency or increased abdominal pressure from persistent coughing or abdominal obesity. Uncomplicated urethral prolapse may be treated conservatively with sitz baths and estrogen cream. Complicated urethral prolapse causing urinary obstruction, tissue necrosis, or persistent bleeding and pain should be referred to urology as it may require surgical treatment (Ballouhey et al. 2014).

Hemorrhoids Hemorrhoids are dilated anal veins caused by venous stasis and exist in two forms, internal and external. Internal hemorrhoids originate from veins in the anal canal and may remain internal or prolapse through the external anal sphincter. External hemorrhoids are dilated perianal veins distal to the external anal sphincter (Fig. 15). The most common symptom of hemorrhoids is painless anal bleeding after defecation, which commonly presents as blood on the toilet paper after wiping the anus. In contrast, prolapsed internal hemorrhoids and thrombosed external hemorrhoids are often painful. Caretakers and medical providers may mistake hemorrhoids for anal bruising due to sexual abuse or correctly identify them but mistakenly believe that they were caused by anal penetration. However, hemorrhoids in the pediatric population are most commonly due to chronic constipation (SanchezAvila et al. 2018) and liver failure. Hemorrhoids are often diagnosed by direct visualization and digital rectal examination, but in some cases anal speculum exam or anorectoscopy is needed. The treatment of hemorrhoids is primarily conservative and directed at correcting the underlying cause. In rare cases refractory to

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Fig. 15 An external hemorrhoid at 11 o’clock and a large perianal skin tag versus perianal pyramidal protrusion from 12 o’clock to 2 o’clock in a 5-year-old female with a history of chronic constipation

conservative management, surgical procedures may be indicated. Resolved external hemorrhoids may result in the formation of perianal skin tags (which were discussed previously in the “Normal Anogenital Anatomy Mistaken for Genital Injury” section of this chapter).

Rectal Prolapse Rectal prolapse is herniation of the rectal mucosa and/or wall through the external anal sphincter resulting in an erythematous mass protruding from the anus that may bleed but is usually painless. Due to its clinical appearance, caretakers may mistake rectal prolapse for a traumatic injury due to anal penetration. However, in the United States, pediatric rectal prolapse is most commonly due to underlying medical conditions, such as chronic constipation (Sanchez-Avila et al. 2018), acute diarrhea, neurologic disorders, anatomic defects, and malabsorptive disorders. The diagnosis of rectal prolapse is based on the history and physical examination. Treatment should prioritize reduction of the prolapse through the application of sugar for osmotic shrinkage and/or manual reduction because reduction becomes increasingly difficult with time. After reduction, treatment should focus on correcting the underlying condition causing the prolapse to prevent recurrence. In most cases, conservative management with stool softeners is sufficient to prevent further prolapse, but in rare cases, recurrent rectal prolapse may require treatment with sclerotherapy or surgery.

Nonabusive Vesicular and Ulcerative Conditions There are many nonabusive vesicular and ulcerative medical conditions that may present in the anogenital region and be confused for genital herpes, syphilis, and other STIs from sexual abuse. Although STIs should always be in the differential when anogenital vesicles and ulcers are encountered, other nonabusive causes must also be considered. Nonabusive anogenital vesicular and ulcerative conditions can be classified by their etiologies as listed in Table 1 below. Several of the more commonly encountered nonabusive vesicular and ulcerative disorders are described in more detail below.

Infectious Impetigo Epstein-Barr virus (EBV) Cytomegalovirus (CMV) Multiple other non-sexually transmitted respiratory viruses

Autoimmune Systemic lupus erythematosus (SLE) Bullous, vulargis, vegetans, paraneoplastic, and mucous membrane pemphigus Linear IgA disease Epidermolysis bullosa acquisita

Genetic HaileyHailey diseasee

Table 1 Nonabusive vesicular and ulcerative conditions listed by etiologic class Inflammatory Crohn’s disease Behçet’s disease Aphthous ulcers Complex aphthosis

Drug-induced Stevens-Johnson syndrome Acute disseminated epidermal necrolysis Bullous fixed drug eruption

Other medical disorders Pyoderma gangrenosum Erythema multiforme Lymphangiectasia Lymphangioma Mucinous cysts Vulvitis circumscripta plasmacellularis Vulvar atopic dermatitis Retained vaginal foreign bodies, especially batteries

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Crohn’s disease Crohn’s disease is a relapsing, chronic inflammatory bowel disease that can involve any portion of the gastrointestinal (GI) tract from the mouth to the anus. Crohn’s disease typically presents with perianal edema, ulcers, fissures, and abscesses, which can be mistaken for trauma from sexual assault. Although rare, patients with Crohn’s disease can develop “metastatic” Crohn’s disease, which occurs when there are extra-intestinal, cutaneous, non-caseating granulomatous lesions separated from affected bowel by normal skin. Metastatic Crohn’s disease can involve the perineum and vulva, which is referred to as vulvar Crohn’s disease. Perineal and vulvar Crohn’s disease present with red or purple granulomatous plaques, nodules, or ulcers that may progress to fistulas. The treatment of perineal and vulvar Crohn’s disease is the same as that for perianal Crohn’s disease, which is oral and/or topical steroids alone or in combination with other systemic Crohn’s disease medications. Behc¸et’s Disease Behçet’s disease is a relapsing–remitting, systemic autoinflammatory disease that presents with recurrent oral and genital ulcers and ocular involvement. Behçet’s disease may also present with other cutaneous lesions (e.g., skin aphthae, erythema nodosumlike lesions), arthritis, and systemic involvement of the gastrointestinal, nervous, and vascular systems. The onset of Behçet’s disease is more likely to occur during young adulthood but may occur during childhood (Karincaoglu et al. 2008). Oral aphthous ulcers are the most common presenting symptom in the pediatric population, as opposed to genital ulcers alone, which are the presenting symptom in only 6% of pediatric Behçet’s disease cases (Karincaoglu et al. 2008). Behçet’s disease affects males and females proportionally, but the course is usually more severe in males (Yazici et al. 1984), although females are more likely to have genital ulcers (Tursen et al. 2003). Genital ulcers and skin aphthae are more likely to result in scars than oral ulcers. Due to the possibility of Behçet’s disease, a child who presents with genital ulcers should have an oral exam conducted to evaluate for oral aphthous ulcers and a thorough full-body skin examination, including the anogenital mucosa, to evaluate for active ulcers and scars from healed ulcers. The etiology of Behçet’s disease remains unclear but involves immune system dysregulation likely caused by infectious and environmental triggers in genetically predisposed individuals. The main goal of treatment for Behçet’s disease is to prevent secondary organ damage. Treatment options for Behçet’s disease vary depending several factors, but include topical corticosteroids, calcineurin inhibitors, systemic corticosteroids, antiinflammatories, and monoclonal antibodies.

Gynecologic Neoplasias Pediatric gynecologic neoplasias are rare, but often present with genital bleeding that can be mistaken for trauma from sexual assault. Neoplasias that affect the reproductive organs or genitalia of children include stromal carcinomas,

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rhabdomyosarcomas, and germ cell tumors. The vast majority of pediatric gynecologic neoplasias are not visible on exam, with the exception of sarcoma botryoides, which can present as “cluster of grapes” mass in the vulva. Once genital trauma has been eliminated as the cause of genital bleeding, pediatric gynecologic neoplasias can often be identified with imaging studies.

Vascular and Lymphatic Conditions Vascular and lymphatic conditions of the genitalia are rare, but when present they can be mistaken for infections or injuries from sexual abuse. Vascular and lymphatic conditions such as hemangiomas and capillary, venous, arterial, lymphatic, and combined vascular-lymphatic malformations can present anywhere on the body, including the anogenital region. Anogenital hemangiomas and vascular malformations may be confused with abrasions, ecchymoses, and submucosal hemorrhages from sexual assault. Lymphangiomas and lymphangiectasias result in dilated lymphatic vessels filled with lymph fluid that can be mistaken for vesicles from sexually transmitted infections.

Hidradenitis suppurativa Hidradenitis suppurativa, also known as acne inversa, is a chronic, inflammatory skin disease that presents with recurrent flares of painful subcutaneous boils that progress to abscesses and sinus tracts. Hidradenitis suppurativa most commonly affects areas of the body that contain apocrine glands, particularly the axillary, inguinal, perineal, perianal, and mammary regions. Hidradenitis suppurativa may result in malodorous discharge from the lesions and scars. Since hidradenitis suppurativa nodules are common in the inguinal and anogenital regions, medical providers who are not familiar with this condition may mistake these lesions for an STI or healed trauma from sexual assault. The exact cause of hidradenitis suppurativa is unknown but it is thought to be due to a combination of genetic factors with environmental triggers, in particular obesity, causing immune dysregulation in response to occluded, inflamed, and infected hair follicles. Treatment of hidradenitis suppurativa depends on disease severity and includes topical antibiotics, systemic antibiotics, and monoclonal antibodies. Research on hidradenitis suppurativa in the pediatric population is limited, but the estimated prevalence is approximately 28 per 100,000 children 1 of the following: 1. Persistent inattention to personal hygiene and/or environment 2. Repeated refusal of some/all indicated services which can reasonably be expected to improve quality of life 3. Self-endangerment through the manifestation of unsafe behaviors (e.g., persistent refusal to care for a wound, creating fire-hazards in the home)

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prevalence of self-neglect is unknown because it is estimated that only 1 in five cases of self-neglect are detected and/or reported to APS agencies thus missing 80% of the cases; the agencies charged with investigating and providing protective assistance to those found to meet individual state or county-based statute definitions. The last national prevalence study of APS agencies found that between 30.7% and 50.2% of APS referrals included an allegation of self-neglect (Teaster 2002). A more recent national population-based study conducted by Acierno et al. (2010) surveyed community living older adults without cognitive impairment and found that medical neglect occurred in 5.1% of the cases. There is evidence that self-neglect prevalence varies based on race/ethnicity, gender, and nationality. In a population-based cohort study, Dong et al. (2012c) reported significantly higher rates of self-neglect for African Americans compared to Caucasians. In this cohort, self-neglect occurred in 21% of the African-American sample compared to 5% in the Caucasian sample. Across gender and ethnicity, 13.2% of African-American males and 2.4% of Caucasian males and 10.9% of African-American females and 2.6% of Caucasian females were validated for self-neglect. A population-based cohort study among US Chinese elderly found a self-neglect prevalence ranging from 10.9% moderate to severe self-neglect to 18.2% mild self-neglect. The majority of the Chinese elderly were found to be living in extremely unsanitary environments (Dong 2014).

Morbidity and Mortality Self-neglect, like other forms of mistreatment, has substantial morbidity and mortality consequences. Compared to older adults without confirmed self-neglect those who self-neglect have significantly higher rates of emergency department visits, hospital admissions, 30-day re-admission rates, and hospice admissions. Moreover, individuals who self-neglect had shorter times spent on hospice and had shorter times between hospice admission and death (Dong et al. 2012a, b; Dong and Simon 2015; Dong and Simon 2013). These were dose-response associations between selfneglect severities (i.e., mild, moderate, and severe) and these outcomes after controlling for a host of social, cognitive, medical, and physical conditions. Older adults found to self-neglect also experience higher rates of nursing home placement (Lachs et al. 2002). In addition to morbidity, this population faces significantly higher rates of mortality. The earliest population-based mortality study conducted by Lachs et al. (1998) reported a threefold increase in 13-year all-cause mortality for APS substantiated cases of self-neglect when compared to demographically matched cohort members. A more recent study completed in 2009 reported a twofold increase in 9-year allcause mortality for self-neglecters when compared to demographically similar cohort members who did not self-neglect (Dong et al. 2009). Ethnicity-related differences in self-neglect mortality have also been found with African-Americans reportedly suffering a twofold increase in all-cause mortality 6-months after being reported to APS compared to Caucasians. Importantly, all of these studies sought to control for a host of medical, physical, cognitive, social, and demographic variables that may confound the associations. The findings suggest that the act of self-neglect alone has a negative impact on morbidity and mortality.

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Phenotype and Detection Historically, self-neglect was described as Diogenes syndrome (i.e., hoarding). With growing awareness and reports, self-neglect has been reframed to include a much broader set of presentations and behaviors beyond that of extreme item collection and environmental clutter. Commonly self-neglect includes some combination of disheveled appearance with poor grooming and hygiene, unsanitary and unkempt living environments including clutter, untreated or poorly self-managed medical, cognitive and/or physical conditions, and living in social isolation or within a suboptimal social network. Some may be living without utilities such as running water and/or electricity and may take limited action to secure food and adequate shelter or medical care (Dyer et al. 2007b). Although the determination of self-neglect is considered as present or not present, evidence suggests that it occurs along a continuum of severity across one or more domains. Dong et al. (2009) have clearly demonstrated that self-neglect ranges between mild, moderate, and severe with dose-response associations to risks for various poor outcomes. Likewise, a study by Burnett et al. (2014) challenged the assumption that self-neglect is a global breakdown in attending to different areas of one’s life and found that it may present in one of four categories (i.e., global selfneglect, physical and medical neglect, environmental neglect, and financial neglect). (See ▶ Chap. 187, “Recognizing the Trauma Experienced by Community-Dwelling Older Victims of Financial Abuse Perpetrated by Trusted Others”). What should be considered in regard to all of these and any other self-neglect presentations and behaviors is that there is a recognized element of immediate and/or potential endangerment of the individual due to their behaviors.

Etiology of Self-Neglect Like any condition that negatively impacts a person’s health and well-being regardless of demographic or socioeconomic indicators, one of the most important questions for prevention and intervention concerns etiology. Understanding the precipitous factors that work together to increase the probability of self-neglect behavior(s) is critical. The lack of longitudinal studies across the life course and even in age-segments of the population, that include self-neglect as a behavioral measure, limit the availability of temporal data necessary to facilitate a robust evidence-based etiology model of selfneglect. Nevertheless, the use of large cross-sectional biopsychosocial data within the self-neglect population and subsequent studies linking biological, cognitive, functional, and social factors to self-neglect have resulted in a supported evidence-based etiology model of self-neglect. This model is presented below in Fig. 2 and was developed by Dyer et al. (2007a) based on over 500 APS-validated cases of older adult self-neglect who received comprehensive geriatric assessments. Self-neglect behavior is likely a product of reciprocal determinism, meaning that the behavior likely influences deficits in certain important life domains, these life domains also likely influence the development of self-neglect. This model focuses on how biological, mental health, cognitive, functional, and social deficiencies work together to increase the likelihood of self-neglect. Each section of the model and its supporting evidence is described below.

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Fig. 2 Self-neglect etiology model

Biological and Psychological Factors Self-neglect has been strongly linked to a host of biological and psychological factors such as diabetes and cerebrovascular disease (Dyer et al. 2007), dementia (Dyer et al. 2000), depression (Dyer et al. 2000; Abrams et al. 2002; Hansen et al. 2016), and nutritional deficiencies (Dong et al. 2010b; Smith et al. 2006). All of these factors have the potential to negatively impact a person’s cognition and have evidence linking them to impairments in memory as well as executive function. For instance, depression result in impaired executive function or the ability to plan, sequence, and carry out tasks necessary for maintaining safe and independent living. Likewise, nutritional deficiencies such as vitamin B-12, folate, and vitamin D have all been linked to poor cognitive functioning including executive function and have been shown to be lower in self-neglecters compared to demographically similar older adults (Dong et al. 2010b). Cognition, Memory, and Executive Function Cognition is a vital component of safe and independent living because it allows us to learn and process information from experiences to inform necessary decisions and actions for safety and independence. Several studies have reported cognitive decline in older adults who self-neglect. Dong et al. (2010b) found that global cognition, measured using the Mini-mental State Exam, Symbol Digit Modalities Test, and the East Boston Memory Test did not predict whether or not an older adult was validated as a case of self-neglect by APS. However, their combined scores on this battery of dementia, executive function, and episodic memory tests were associated with selfneglect severity. The most important predictor of validation of self-neglect by APS was executive dysfunction. This suggests that when executive dysfunction is present, an older adult is at increased risk for self-neglect. In a separate study, Pickens

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et al. (2014) assessed the executive function of 50 older adults with APS validated self-neglect and found that a significant portion of the sample had impairments consistent with executive dysfunction in the areas of concept generation, planning inhibition, and spatial working memory. In other words, these individuals were deficient in their ability to plan or manage current and future tasks or remember information about their environment and spatial orientation. Without these sorts of abilities, it is easy to understand how an older adult may be unable to complete basic and instrumental activities of daily living.

Impaired Activities of Daily Living Proficiency in basic and instrumental activities of daily living (ADLs) is critical for safe and independent living. These activities include bathing, cooking, grooming, transitioning from one place to another, handling finances, finding transportation, and taking medications. In 2008, Naik et al. (2008), Naik reported that communitydwelling self-neglecters had significantly higher basic ADL impairments compared to a demographically similar comparison group based on a physical performance test. Using an objective performance-based assessment, Pickens et al., also reported that self-neglecters were significantly less able to complete critical basic and instrumental ADLs to remain safe and independently living in the community when compared to a demographically matched comparison group. A later study by Dong et al. (2009) found that physical function decline as well as the inability to adequately complete basic and instrumental activities of daily living were risk factors for being reported to APS and validated for self-neglect. Inadequate Support Services When someone faces any deficit that negatively impacts his or her ability to provide adequate self-care and self-protection, social support services become critical and can be the safety net between falling into a pattern of self-neglect or remaining safe. This is especially true among those with high medical disease burdens who may require some assistance to manage their self-care and adhere to medical regimens. Multiple studies have reported that self-neglect is associated with social isolation (Abrams et al. 2002; Dong et al. 2009). A study by Burnett et al. (2007) found that social networks for community dwelling self-neglecters were extremely limited. Within this study, self-neglecters were significantly more likely to live in social isolation than a demographically similar comparison group and even among those that reported having social networks; they reported low engagement with family, friends, neighbors, and religious organizations. This lack of support services may not only be social, but could also be related to extrinsic factors such as living in poverty or having a low education. In a population-based cohort study, Dong et al. (2010a) found that low education and income were associated with self-neglect compared to non-self-neglect. In populations other than self-neglect, these factors are associated with lower health literacy as well as access to medical and social support services. Therefore, if an older adult living in isolation is unable to manage certain aspects of their life, afford transportation or medical care, or needs assistance with obtaining other necessities such as food and

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adequate shelter, but does not have the appropriate support services, they are much more likely to fall into a pattern of self-neglect.

Intentional or Unintentional Neglect A significant portion of those who are abandoned or neglected or self-neglecters lack decision-making capacity. Persons who lack decision-making capacity often reject assistance or are unable to recognize when care is substandard. Adults who possess decision-making capacity are autonomous and have the right to make decisions that may negatively impact their health. This includes refusing support services when they could be helpful in mitigating harm. If they are able to make this decision then this would fall into the category of intentional self-neglect. However, if they are unable to communicate a choice, understand the decision, appreciate the risks and benefits, and rationalize the reasoning for making the choice, then they may lack decision-making capacity and their decision to refuse services falls into the unintentional self-neglect category. In this case, appropriate actions by APS or other social service agencies can be taken to prevent this person from further harm. Etiologic Model Summary Biological, psychological, cognitive, physical, plus social and extrinsic factors may play an important role in the development of self-neglect. The proposed etiologic model of self-neglect is only one proposed model but has received considerable support. While not every case of self-neglect may follow this model, it is plausible to assume that many do and this provides targets for future prevention and intervention.

Prevention and Intervention Detection and Reporting Detecting self-neglect is difficult because these older adults often remain isolated and suspicion is not always raised when they stop attending social gatherings. Many of these cases are hiding in plain sight. There are opportunities for detection that come through the raising of awareness of the presentation(s) of self-neglect. Family members and health professionals and others can be vigilant of changes in self-care and environmental cleanliness habits, the ability to manage finances, reductions in social engagement or inconsistencies in what the older adult says they are doing and what they are really doing. Several objective measures of self-neglect have been developed to assist with detection (Kelly et al. 2008; Iris et al. 2014). These assessments can be used irrespective of professional background and require very little training as they mainly rely on objective assessments of hygiene, environmental clutter, sanitation, cleanliness, and insect and rodent infestations. Self-neglect is reportable to in all of the state APS programs except Delaware, Illinois, one of two programs in Massachusetts and Vermont. In some states, such as Texas, mandatory reporting laws requires all citizens to refer suspected cases to APS. These agencies often have an anonymous reporting system to protect the relationship between the reported and self-neglecter.

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Intervention Intervening in self-neglect can be extremely difficult because of the complexity of issues that surround it. The autonomy of adults who are neglecting themselves, who have decision-making capacity and are not placing others must be respected. In cases where medical and psychological professionals are able to determine that a person lacks decision-making capacity intervention may become easier because autonomy is no longer an issue. In these cases, conservatorships or guardianships can be put in place to ensure that the person has the necessary resources for living safely and sometimes, even independently.

Impact of Abandonment and Neglect Interconnections with Other Types of Violence Lack of Decision-Making Capacity Is the Unifying Theme of Elder Mistreatment In most forms of mistreatment, there is a unifying theme of the loss of capacity for decision-making and self-protection. While frank abuse and battering may be more common in those with physical frailty, clearly older adults who lack mental capacity can become victims of every form of mistreatment. This lack of capacity may manifest in several ways. The elder may not detect someone with less than honorable motives. They may have executive dysfunction which is the inability to plan, sequence, and carry out tasks. Therefore, the elder may not be able to perform their activities of daily living independently. Often with executive dysfunction, older adults fail to edit and thus hoarding and/or squalor ensue. They may not know how to obtain the additional help they might need with transportation, finances, or personal care. They may not know how to report mistreatment to law enforcement or APS. Although all individual of any age are targets for scams and frank theft, elders who lack full decision-making ability are easier targets for those who want to exploit or abuse or neglect them. Older adults are often more trusting of strangers as well as family members who may wish to use the senior’s money. Neglected individuals may not recognize the neglecter nor know how to remedy a bad or even dangerous caregiving situation. In the most severe cases, there is lack of capacity for self-care and self-protection. Outcomes of the most severe cases include large pressure ulcers, uninhabitable homes, and death. Capacity assessments are key to the investigation and intervention in all cases of elder mistreatment. It is critically important for APS workers and other agencies to be able to obtain capacity assessments on their clients before they intervene. This way, the autonomy of persons with capacity will be respected and those without capacity will be able to receive the assistance they need. Neglect Versus Self-Neglect It can be very difficult to differentiate neglect from self-neglect. One can see from the discussions above that the phenotypes for neglect versus self-neglect are similar if

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not nearly the same. The distinction is difficult for the trained and untrained individual. In a 2006 study, Dyer et al. (2006) surveyed 25 APS workers; 44% felt that the factor which indicated self-neglect versus neglect was nothing more than the presence of a caregiver. Many of the remedies or interventions for the person such as increased health care and caregiver support are the same for both self-neglect and neglect. It is quite possible that cases of neglect start out as self-neglect. Imagine that an independently functioning older adult without children begins to develop cognitive impairment. Over time his nutrition and hygiene begin to deteriorate. He stops seeing the physician, so his health declines. Without family or a caregiver, this case is considered self-neglect. Take the same case but this time there is a daughter involved. They have been mostly estranged and she reluctantly steps in to help. She realizes that caring for her dad takes a lot more work than she had thought. She is unable to fulfill the necessary tasks and her father declines further. The latter scenario is considered neglect. Abandonment leads to self-neglect cases of frail elders who cannot perform the Activities of daily living (ADL’s). Why is it important to distinguish between the two? Screening usually involves the physical signs and facts from the history. Mortality and morbidity are increased in both neglect and self-neglect. In most states, both are reportable to Adult Protective Services, so it makes sense to screen. Interventions require the same physical, psychological, and environmental strategies. Neglect cases may warrant legal action against the perpetrator, although sadly few cases are ever prosecuted. Self-neglect cases may require the expertise of a civil attorney if guardianship is required. Researchers may want to distinguish between the two for studies. But beyond academic interests, whether self-neglecting or neglected, the human toll is the same and both are worthy of scrutiny and intervention.

Social Justice Implications The concept of social justice originated with St. Augustine of Hippo (354–430 AD). A prolific writer, he wrote about concepts such as preferential option for the poor and sharing what one has with others. Anyone who has seen a case of neglect or selfneglect knows that they evoke strong feelings of concern, compassion, and the desire to help as well as the fear that he or she could someday experience these phenomena themselves. Abandonment and neglect are so prevalent and devastating that they require a community response.

Human Suffering It is difficult to image how it must feel to live or be left in squalor or have one’s most basic needs ignored. Whether the body and mind fail or a family member or caregiver does not take the necessary steps to preserve dignity and health, the negative impact on one’s self esteem is great. Depression was mentioned above as a risk factor for neglect, some feel that depression may be a byproduct of neglect. It is not possible to put into words the sights and smells that are encountered on the home

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visits of neglected individuals. Two dimensional pictures don’t fully depict the depth of pressure ulcers or the claustrophobia one feels in the homes of hoarders. Rotting food, feces, multiple animals in the home create tragic scenes that victims of neglect or self-neglecters must sublimate in order to survive from 1 day to the next.

Training for Health Care Providers Abandonment and neglect cases are present in every sector of society and are seen by workers from multiple disciplines such as health, law enforcement, justice, and social service. Health professionals are in a unique position to assist, diagnose, and protect – yet their training is very scant. As a result, cases are undetected in emergency rooms, clinics, and in the hospital. Adult Protective Service workers, police officers, and officers of the court do not have medical colleagues to guide those concerning medical disorders or help with interventions like emergency removals or prosecution. Every health professional learns about child abuse, with the changing demographics, basic training is needed in all forms of elder abuse, but especially in cases of neglect or self-neglect. It is in these cases that medical issues are most prominent, and all health care workers must be able to recognize, intervene, and work to prevent them. An overlooked area of policy and advocacy, however, is the training required to practice in a nursing home. Geriatricians are trained to care for frail elders in longterm care. This is not the case of general internists. Family physicians get some training in long-term care and in fact a majority of long-term care is delivered by family physicians. The American Medical Directors Association was established in 1977 to help older long-term care patients by training physicians in this arena. They have a didactic course and a course that addressed the business and operations sides of long-term care. This results in a Certificate of Medical Direction or CMD. However, this certification is required of medical directors in only a handful of states. There are no training requirements for the physicians or advanced practice professionals who see patients in these settings. In the twentieth century, when medical care was less specialized, specialties such as pediatrics or infectious disease emerged as new and distinct fields of study. While general internists took care of intensive care patients, with the new field of critical care medicine, specialists now operate the ventilators and place intravenous lines into large blood vessels. Just as neonatology is to pediatrics medicine, geriatrics is to internal medicine. Frail older patients have different physiology and social and physical needs and practices that apply to middle-aged adults are insufficient for older adults. Lack of knowledge of dementia and behavioral problems allows older adults to be undertreated or over sedated. It would seem that policy should require the appropriate training before one can treat a vulnerable older adult. Advocates could be a part of making this a reality. Community Responses Beyond the health profession, communities can help with the ubiquitous problems of abandonment and neglect. It is clear that neglect results in the lack of social supports and a lack of means to address activities of daily living that an older adult cannot

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provide for him or herself. Many communities already provide senior centers or day centers for adults. The Program of All-inclusive Care for the Elderly or PACE programs serve at-risk seniors with Medicare and Medicaid. These programs fashion medical services and some activity of daily living services around day care centers where older adults attend 2–3x a week. Community caregiver programs that are affordable, accessible, and provides a well-trained work force could definitely help prevent cases of neglect and self-neglect.

Policy and Advocacy Screening Screening for neglect or any type of elder mistreatment is a curious topic. The US Preventative Task Force (2018) concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for abuse and neglect in all older or vulnerable adults. They issued a challenge to elder abuse researchers to work towards the standard of domestic violence. While evidence is clearly important, what about the well-documented mortality risk? The increased risk of hospitalization? What about the human suffering associated with mild to severe neglect? There are many factors that determine whether or not efficacy studies are done – a predominant one is the funding. While these sorts of studies take years and millions of dollars what more evidence is needed to develop policies that strive to detect and even prevent neglect before it happens? Protection of the most vulnerable should be in the forefront of policy discussions about seniors, and advocates could be very helpful in bringing this message forward. Multidisciplinary Team Interventions Much has been written about multidisciplinary teams and their efficacy. The cases are often complex and multidimensional. They are teams of professionals from various disciplines such as law enforcement, protective services, social work, health care, civil and criminal law, as well as forensics. These teams share information thus reducing work load and leverage the strengths of their members. Many of these teams form organically. Several community leaders get together recognize a need and teams “spring up.” Members who participate in these teams often find them beneficial to their clients or patients in terms of outcomes and efficiency. They often find it gratifying to work collaboratively with members of other disciplines. The fact is that these teams mostly function out of the interest and good will of the participants and the leaders of their organizations. They take time and dedication. Often the participants are from nonprofit or governmental organizations. Not unlike the argument for policy on screening, there is a prima facie argument to be made for establishing multidisciplinary teams. Anyone who has taken a course on team building knows that the outcomes of teams exceed what one or two individuals can do. It would seem prudent to have local and state policies on multidisciplinary teams. Although forming well-functioning teams takes some upfront time, technology with videoconferencing makes teams meetings more

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convenient and feasible. It would serve communities well if there were funding and policies for the formation of multidisciplinary teams.

Training Elder Mistreatment Experts In 2005, the American Board of Pediatrics accepted Child Abuse as a separate medical specialty for Pediatricians. The fellowship is 3 years long and enables diplomats of the American Board of Pediatrics to sit for the specialty board examination in child abuse. There are currently 30 programs around the USA. This same sort of training could be possible in elder mistreatment. Perhaps a 6-month certificate could be developed as start, especially considering that geriatric medicine training is 1 year. As mentioned above, the determination of decision-making capacity is critical to evaluation and intervention of elder mistreatment cases and is not taught generally to physicians. It might be prudent to also certify advanced practice professional like nurse practitioners and physician assistants many of whom work in emergency department and long-term care facilities. The literature on elder mistreatment is growing, but the skill sets and experience needed are likely best taught through experiential learning.

Where the Field Is Going Forensic Centers: When Neglect Is Criminal Lack of prosecution is considered a major barrier to the prevention of elder abuse including neglect. In the early 2000s, forensic centers began in California to address the legal issues concerning elder mistreatment. There are a few around the country now, and these centers bring together a multidisciplinary team including prosecutors, civil attorneys, and protective service workers. Law enforcement and medical professionals to develop and work cases as a team. The goals of many of these centers include referrals for prosecution and convictions. Many also offer resource referrals to the frail victims they serve. Research Around Dementia At the time of the writing of this chapter in 2018, there is a heightened focus on dementia at the National Institute of Aging. In fact, the pay line is the highest in years. Alzheimer’s’ disease and related dementias is considered a separate research area and is receiving even greater funding in the current Administration. Studies could include both community dwelling older adults as well as nursing home residents. Since dementia patients are so vulnerable and at significant risk for neglect, this area should prove fruitful for elder abuse researchers. Telehealth Telehealth is fast becoming a method of choice for health evaluations and monitoring. It is used in nursing home practices, psychiatry assessment, and for evaluation of minor illnesses and post hospital follow up. In 2017 in the state of Texas, telehealth technology was introduced for capacity evaluation of abused and neglected

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individuals. The team of geriatrician and elder abuse experts can now evaluate Adult Protective Service clients all over the state even in the most remote rural regions. The program is part of the Texas Elder Abuse and Mistreatment Institute (TEAM) and is called the Forensic Assessment Center Network (FACN). Medical and other records can be uploaded and evaluated, and Adult Protective Service Workers receive a full report. State officials have noted both increased efficiency and numbers served. Outcome studies are underway and programs like this are likely to arise in other states.

Key Points • Neglect by caregivers is prevalent and results in serious medical illness and death. • The consequences of self-neglect are as serious as those of caregiver neglect. • Illness and old age lead elders to become more vulnerable to neglect and abandonment. • Health care professionals as well as those from the fields of law enforcement, criminal and civil justice, social work, nursing, and others should be familiar with the specifics of neglect and abandonment. • Policy and advocacy should focus on solutions including better community support systems, screening, and multidisciplinary teams. • Future directions include more directed research, and the use of technology.

Summary and Conclusion As adults age, they often become more vulnerable to harm. These harms may come at the hands of others through direct actions or the omission of needed care. The aging parabola sets up a trajectory to be able to live independently and protect oneself from harm; in many cases, these abilities diminish over time. While all strive for independence in young and old age, age-related biological, psychological, functional, cognitive, and social changes are likely to occur. Many if not most people will experience a period of disability in old age. The lack of support services or abandonment lead to self-neglect and malfeasance or lack of caregiving ability lead to neglect. Social justice practices should account for these inevitable changes and society put safety nets in place for the protection of older adults. This is accomplished through good community support systems, which include: better screening practices, the training of health care professionals and members of other disciplines, as well as more community-based multidisciplinary intervention teams. Future work to prevent neglect and abandonment should involve more research, more forensic evaluation centers, as well as the utilization of telehealth and telecommunication techniques. These strategies will help prevent or at least forestall the serious negative health impact of neglect and abandonment and provide senior members of society with the dignity and respect they deserve.

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Cross-References ▶ Caregiving and Elder Abuse: A Complex Relationship ▶ Intersectionality of Elder Abuse and Mental Health Issues: Needs and Interventions for Victims ▶ Introduction: Abuse in Later Life ▶ Perpetrators of Elder Abuse ▶ Recognizing the Trauma Experienced by Community-Dwelling Older Victims of Financial Abuse Perpetrated by Trusted Others ▶ Systems Responses to Older Adult and Elder Abuse

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Dong, X. (2014). Self-neglect in an elderly community-dwelling U.S. Chinese population: Findings from the population study of Chinese elderly in Chicago study. Journal of the American Geriatrics Society, 62(12), 2391–2397. Dong, X., & Simon, M. A. (2013). Association between elder self-neglect and hospice utilization in a community population. Archives of Gerontology and Geriatrics, 56(1), 192–198. Dong, X., & Simon, M. A. (2015). Elder self-neglect is associated with an increased rate of 30-day hospital readmission: Findings from the Chicago health and aging project. Gerontology, 61(1), 41–50. Dong, X., Simon, M., Mendes de Leon, C., Fulmer, T., Beck, T., et al. (2009). Elder self-neglect and abuse and mortality risk in a community-dwelling population. Journal of the American Medical Association, 302(5), 517–526. Dong, X. Q., Simon, M., & Evans, D. (2010a). Cross-sectional study of the characteristics of reported elder self-neglect in a community-dwelling population: Findings from a populationbased cohort. Gerontology, 56(3), 325–334. Dong, X., Simon, M. A., Wilson, R. S., Mendes de Leon, C. F., Rajan, K. B., & Evans, D. A. (2010b). Decline in cognitive function and risk of elder self-neglect: Finding from the Chicago health aging project. Journal of the American Geriatrics Society, 58(12), 2292–2299. Dong, X., Simon, M. A., Fulmer, T., Mendes de Leon, C. F., Hebert, L. E., et al. (2011). A prospective population-based study of differences in elder self-neglect and mortality between black and white older adults. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 66(6), 695–704. Dong, X., Simon, M. A., & Evans, D. (2012a). Prospective study of the elder self-neglect and ED use in a community population. The American Journal of Emergency Medicine, 30(4), 553–561. Dong, X., Simon, M. A., & Evans, D. (2012b). Elder self-neglect and hospitalization: Findings from the Chicago health and aging project. Journal of the American Geriatrics Society, 60(2), 202–209. Dong, X., Simon, M. A., & Evans, D. A. (2012c). Prevalence of self-neglect across gender, race, and socioeconomic status: Findings from the Chicago health and aging project. Gerontology, 58, 258–268. Dyer, C. B., Pavlik, V. N., Murphy, K. P., & Hyman, D. J. (2000). The high prevalence of depression and dementia in elder neglect. Journal of the American Geriatric Society, 48(2), 205–208. Dyer, C., Toronjo, C., Cunningham, M., Festa, N., Pavlik, V., Hyman, D., et al. (2006). The key elements of elder neglect: A survey of adult protective service workers. Journal of Elder Abuse & Neglect, 17(4), 1–10. Dyer, C., Goodwin, J., Pickens-Pace, S., Burnett, J., & Kelly, P. (2007a). Self-neglect among the elderly: A model based on more than 500 patients seen by a geriatric medicine team. American Journal of Public Health, 97(9), 1671–1676. Dyer, C., Pickens, S., & Burnett, J. (2007b). Vulnerable elders. The Journal of the American Medical Association, 298(12), 1448. Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans 2016: Key indicators of well-being. Retrieved from https://agingstats.gov/docs/LatestReport/Older-Ameri cans-2016-Key-Indicators-of-WellBeing.pdf Fulmer, T., Guadagno, L., Bitondo Dyer, C., & Connolly, M. T. (2004). Progress in elder abuse screening and assessment instruments. Journal of the American Geriatrics Society, 52 (2), 297–304. Haber, D. (2013). Health promotion and aging: Practical applications for health professionals (6th ed.). Springer. Retrieved from https://market.android.com/details?id¼book-_EsSVOyEarMC. Hansen, M., Flores, D. V., Coverdale, J. H., & Burnett, J. (2016). Correlates of depression in community-dwelling older adults with adult protective Services substantiated self-neglect. Journal of Elder Abuse & Neglect, 28(1), 41–56. Iris, M., Conrad, K., & Ridings, J. (2014). Observational measure of elder self-neglect. Journal of Elder Abuse & Neglect, 26(4), 365–397.

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Kelly, P. A., Dyer, C. B., Pavlik, V., Doody, R., & Jogerst, G. (2008). Exploring self-neglect in older adults: Preliminary findings of the self-neglect severity scale and next steps. Journal of the American Geriatrics Society, 56(Suppl 2), S253–S260. Lachs, M. S., & Pillemer, K. A. (2015). Elder Abuse. The New England Journal of Medicine, 373 (20), 1947–1956. Lachs, M. S., Williams, C. S., O’Brien, S., Pillemer, K. A., & Charlson, M. E. (1998). The mortality of elder mistreatment. The Journal of the American Medical Association, 280(5), 428–432. Lachs, M. S., Williams, C. S., O’Brien, S., & Pillemer, K. A. (2002). Adult protective service use and nursing home placement. The Gerontologist, 42(6), 734–739. Lang, F. R. (2001). Regulation of social relationships in later adulthood. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 56(6), P321–P326. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11682585. Lifespan of Greater Rochester, Inc., Weill Cornell Medical Center of Cornell University, & New York City Department for the Aging. (2011). Under the Radar: New York State Elder Abuse Prevalence Study. Retrieved from http://ocfs.ny.gov/main/reports/Under%20the%20Radar% 2005%2012%2011%20final%20report.pdf Naik, A. D., Teal, C. R., Pavlik, V. N., Dyer, C. B., & McCullough, L. B. (2008). Conceptual challenges and practical approaches to screening capacity for self-care and protection in vulnerable older adults. Journal of the American Geriatrics Society, 56(Suppl 2), S266–S270. National Center on Elder Abuse. (2018). An Introduction to Elder Abuse for Professionals: Neglect. Retrieved 10 Oct 2018, from https://ncea.acl.gov/whatwedo/education/curricula.html National Research Council. (2003). Elder mistreatment: Abuse, neglect, and exploitation in an aging America. (R. J. Bonnie & R. B. Wallace, Eds.). Washington, DC: National Academies Press. Retrieved from https://www.nap.edu/catalog/10406/elder-mistreatment-abuse-neglectand-exploitation-in-an-aging-america Pavlou, M., & Lachs, M. (2008). Self-neglect in older adults: A primer for clinicians. Journal of General Internal Medicine, 23(11), 1841–1846. Pickens, S., Otswald, S. K., Murphy Pace, K., Diamond, P., Burnett, J., & Dyer, C. B. (2014). Assessing dimensions of executive function in community-dwelling older adults who selfneglect. Clinical Nursing Studies, 2(1). Pillemer, K., & Finkelhor, D. (1988). The prevalence of elder abuse: A random sample survey. The Gerontologist, 28(1), 51–57. Pillemer, K. A., Mueller-Johnson, K. U., Mock, S. E., Suitor, J. J., & Lachs, M. S. (2007). Interventions to prevent elder mistreatment. In E. N. Haas, L. S. Doll, S. E. Bonzo, J. A. Mercy, & D. A. Sleet (Eds.), Handbook of injury and violence prevention (pp. 241–254). Boston: Springer. Rathbone-Mac Cuan, E. (1992). Self-neglecting elders: A clinical dilemma. New York u.a.: Auburn House. Smith, S., Mathews Oliver, S., Zwart, S., Kala, G., Kelly, P., Goodwin, J., & Dyer, C. (2006). Nutritional status is altered in the self-neglecting elderly. The Journal of Nutrition, 136(10), 2534–2541. Teaster, P. (2002). A response to the abuse of vulnerable adults: The 2000 survey of state adult protective services. [Ebook]. Washington, DC: National Center on Elder Abuse. US Preventive Services Task Force. (2018). Screening for intimate partner violence, elder abuse, and abuse of vulnerable adults. US Preventive Services Task Force Final Recommendation Statement. The Journal of the American Medical Association, 320(16), 1678–1687. Vierthaler, K. (2008). Best practices for working with rape crisis centers to address elder sexual abuse. Journal of Elder Abuse & Neglect, 20(4), 306–322. Dong, X., Simon M. A., & Evans D. A. (2012). Prevalence of Self-Neglect across Gender, Race, and Socioeconomic Status: Findings from the Chicago Health and Aging Project Gerontology 58, 258–268.

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Section I: Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A Definition of Polyvictimization in Later Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Theoretical Constructs and Explanatory Frameworks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Socio-Ecological Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Advancing the Contextual Theory of Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Polyvictimization Research in Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Studies on Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Studies on Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Polyvictimization by Surrogate Decision-Makers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Older Adult Polyvictims Amidst the Opioid Epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Section II: Clinical and Sociological Reflections on Polyvictimization . . . . . . . . . . . . . . . . . . . . . . . Clinical Case Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sociological Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Future Directions for Research and Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. P. B. Teaster (*) Center for Gerontology, Virginia Tech, Blacksburg, VA, USA e-mail: [email protected] H. Ramsey-Klawsnik Klawsnik & Klawsnik Associates, Canton, MA, USA © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_89

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Abstract

Polyvictimization in later life concerns mistreatment by multiple perpetrators as well as mistreatment involving different types of abuse, co-occurring or sequentially. This chapter includes both a rationale and history for the application of the term to older adults and the definition of polyvictimization in later life. In addition, we discuss highlights concerning what is presently known about polyvictimization in later life. We describe how polyvictimization may be used relevant to the socio-ecological framework as well as other frameworks. We explain how polyvictimization at younger ages differs from polyvictimization in later life and include a case example involving an older victim that illustrates abuse dynamics as well as links between elder abuse and other forms of interpersonal violence, including polyvictimization. Finally, we make suggestions for how our definition of polyvictimization in later life may be used in research, practice, and policy arenas. Keywords

Polyvictimization · Elder abuse · Mistreatment · Intimate partner violence · Surrogate decision makers · Theory · Framework

Introduction Polyvictimization in later life can produce injurious effects on its victims and their families, as well as society. Although elder abuse often involves more than one type, considering elder abuse as polyvictimization is still a relatively new construct. Consequently, understanding polyvictimization in later life requires new and different ways of examining not only the victims but also those who perpetrate the abusive acts, because the problem becomes increasingly complex as new types are added or one type is repeated and exacerbates the abuse. Understanding how to prevent, interpret, and intervene in cases of polyvictimization demands new ways of thinking about this challenging problem. This chapter is divided into two sections – the first sets the stage for polyvictimization, including definition, theoretical frameworks, and present research. The second section is a case presentation and clinical analysis that illustrates common dynamics present in elder polyvictimization. Sociological considerations and an analysis of the linking of various forms of interpersonal violence to elder abuse and polyvictimization conclude the chapter.

Section I: Background In 2012, the National Committee for the Prevention of Elder Abuse received an award from the Office for Victims of Crime, Office of Justice Programs, and US Department of Justice to advance knowledge and enhance awareness of

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polyvictimization in later life. Goals of the grant were to explore the existing research and practice literature in order to develop a definition of polyvictimization in later life, hold a national forum on polyvictimization, create a web-based training curriculum (Ramsey-Klawsnik et al. 2017), and publish a special issue of the Journal of Elder Abuse and Neglect.

A Definition of Polyvictimization in Later Life The definition of polyvictimization was crafted using definitions of elder abuse and neglect developed by the National Center on Elder Abuse (NCEA 2001) and advanced by the Elder Justice Roadmap (2014). The Elder Justice Roadmap Project, a groundbreaking partnership within the elder justice field, its allies, and the federal government, created a national strategic plan and used a behavioral definition to define elder abuse: (1) any physical, sexual, or psychological abuse, as well as neglect, abandonment, and financial exploitation of an older person by another person or entity (2) that occurs in any setting (e.g., home, community, or facility) and (3) committed by a person or persons either in a relationship where there is an expectation of trust and/or when an older person is targeted based on age or disability. Similarly, the Centers for Disease Control and Prevention (CDC) (2016, p.28) described elder abuse as “An intentional act or failure to act by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult.” Research revealed that some elder abuse literature referred to “multifaceted abuse,” “multiple victimization,” or “hybrid or co-occurring forms of elder abuse” (Acierno et al. 2010; Lifespan of Greater Rochester 2011). Both research and practice findings support the acknowledgment of complex victim experiences and needs that are the hallmark of polyvictimization. For example, Turner et al. (2010) studied children and defined polyvictimization as lifetime exposure to multiple victimization types, a condition affecting individuals experiencing several varieties of victimizations or exposures to violence, crime, and abuse. For children, undergoing multiple types of abuse is associated with more intense mental health symptoms than those experiencing a single type of abuse. Polyvictimization (i.e., two or more categories) predicted negative symptoms (Hickman et al. 2013). Findings from child abuse studies indicate that polyvictimization persists over time, producing cumulative effects. Studies on polyvictimization of children revealed that exposure to one type of violence puts victims at greater risk of experiencing other types, sparking a pattern of ongoing or escalating victimization and complex trauma (Finkelhor 2012). Child victims of polyvictimization exhibit intense and long-lasting consequences, such as lifetime adversity and psychological stress, psychosocial and functional impairment, and post-traumatic stress disorder (Ford et al. 2011). Though most research on polyvictimization concerns children and young adults, it also occurs in later life and likely has deleterious effects. Older adults may be incapable of recouping losses caused by multiple or ongoing forms of abuse and

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losses exacerbated by attributes unique to older ages: exit from the workforce, reduced social networks, decreases in finances, the manifestation of multiple and chronic diseases, and declines in cognitive ability. Other losses may include loss of independence, a sense of safety, and relocation away from a community setting. Drawing from relevant research and practice literature on child polyvictimization described above, as well as listening carefully to leaders in the field, the Project Team developed the definition of polyvictimization in later life below. Polyvictimization in later life occurs when a person aged 60 or older is harmed through multiple co-occurring or sequential types of elder abuse by one or more perpetrators, or when an older adult experiences one form of abuse perpetrated by multiple others with whom the older adult has a personal, professional, or care recipient relationship in which there is a societal expectation of trust. Perpetrators of polyvictimization in later life include individuals with special access to older adults, such as intimate partners, other family members, fiduciaries, paid or unpaid care or service providers, and resident(s) or service recipients in care settings.

Recognizing that polyvictimization is more often found in situations of elder abuse involving family members, within trusted relationships, or involving situations in which an obligation for care exists, the Project Team excluded cases of victimization in which the perpetrator is unknown to the victim or has no special relationship of trust. The definition put forth priority to people with special access to older adults who have a trust relationship with the older adult.

Theoretical Constructs and Explanatory Frameworks As a scholarly endeavor, elder abuse research was developed since the early 1970s. Not surprisingly, theory development in the field lagged and borrowed frameworks and theories from other areas (e.g., criminology, sociology, psychology). No one theoretical concept or framework suited the complexities inherent to elder abuse, but the Project Team determined that the socio-ecological framework was most apropos to the definition created. Due to space limitations, this chapter does not review frameworks or theories other than the socio-ecological framework; for a treatment of other theories and frameworks, see Roberto and Teaster (2017).

The Socio-Ecological Framework The Project Team chose the socio-ecological model by Bronfenbrenner (1986) because of its understandability and applicability to the complex problem of elder abuse. Also used by the Centers for Disease Control and Prevention (CDC 2009), the framework helps elucidate violence and prevention strategies as well as risk factors and the environment in which conditions for polyvictimization might emerge. Though originally conceptualized for children, the framework uses a microsystem

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through macrosystem level approach. At the center of the framework is the victim. Applied to polyvictimization, the framework allows for the recognition that older adults are embedded in a series of environmental systems. The framework centers on the characteristics of an older adult and four influencing systems: (a) the microsystem, or the victim in his or her environment; (b) the mesosystem, or the relationship between the older adult and the perpetrator (e.g., relative, friend, caregiver); (c) the exosystem, or environments peripheral to the older adult (e.g., community services, law enforcement) that affect well-being; and (d) the macrosystem, incorporating ideological values, norms, and cultural and institutional patterns (Horsford et al. 2011). The socio-ecological framework allows acknowledgment that polyvictimization of older adults demands informed, coordinated responses drawing upon multiple levels of intervention. In research on elder abuse, the socio-ecological framework has been used to examine abuse factors by caregiving adult children (Schiamberg and Gans 1999), intervention (Wangmo et al. 2014), prevention (Reilly and Gravdal 2012), intimate partner violence (Teaster et al. 2006), and nursing homes (Schiamberg et al. 2012). Mihaljcic and Lowndes (2013) examined macrolevel factors pertaining to individual and community attitudes toward financial elder abuse. Similarly, Lee et al. (2014) used the framework together with the cultural sensitivity model to examine how contextual factors influenced perceptions of elder abuse among 30 Korean and Chinese immigrants and found that core values of their culture and acculturation significantly affected their perceptions of elder abuse and receptivity to interventions. Walsh and Yon (2012) employed the ecological framework to develop an empirical profile for elder abuse research in Canada, including prevalence studies in community and facility settings, examination of correlates, risk and protective factors related to abuse, and research on elder abuse through capacity building. Phelan (2014) used the model to examine political changes in Ireland, which allowed an examination of the multifaceted progress of Irish policy, practice, and legislation related to the protection of older adults.

Advancing the Contextual Theory of Elder Abuse In response to deficiencies of the socio-ecological framework, Roberto and Teaster (2017) proposed the contextual theory of elder abuse, stressing that the field of elder abuse would gain a more coherent, comprehensive, and applicable theoretical framework specifically created for research, practice, and policy on various types of elder abuse. The contextual theory of elder abuse (Roberto and Teaster 2017) places the victim at the center (individual context) and encompasses biological and personal factors that affect how older adults behave, how risk factors increase tendencies toward becoming a victim or perpetrator, and how circumstances, such as chronic disease or dementia, influence people prior to, during, and after an abusive experience. The relational context explains interactions and dynamics between older adults and others, such as care providers, family members, or

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both. The community context includes an older adult’s sense of place and how members relate to one another within the space in which they live, work, worship, and so forth. Finally, the societal context involves overarching ideological ideals and standards that engender an environment where abuse is either condoned or denounced. The societal context involves macrolevel dynamics of power and control dynamics, such as age-related changes in society. As an example, ageism fosters prejudice and marginalization of older adults, which may permit a tacit acceptance of the abuse of older adults. The past trauma that an older adult may have experienced could profoundly affect his or her current condition. Psychological defenses built in youth in order to cope with victimization can erode if the older person is exposed to victimization. Cognitive changes may also intensify reactions. In addition to victimization commencing in old age, some older adults also experienced adverse experiences (e.g., sexual or racial discrimination, poverty, genocide, war). Additionally, a number of older adults came of age in a culture prior to the advent of civil rights; thus, they lived for years without protections offered by child abuse, domestic violence, sexual assault, and civil and disability rights legislation and services. These experiences in the life course of these older adults affect their present identification of elder abuse itself as well as their receptivity to intervention and service provision. Ecological theories facilitate studying elder abuse as a complex problem with various systems as well as coordinated responses from different levels of intervention and prevention. Their strength is also a limitation. The application of ecological frameworks is, at present, used only by a few researchers and tends to be conceptual rather than empirically focused. While the frameworks stress the interrelatedness of systems, explanations for processes and behaviors within and across the various systems have yet to be methodically addressed.

Polyvictimization Research in Context Studies on Children and Adolescents Findings from studies of children and adolescents, such as the adverse childhood experiences (ACE) (Felitti et al. 1998), revealed that cumulative childhood trauma had profound effects more than 50 years later, due to psychosocial stress into organic disease, adult health risk behaviors, fatal illnesses, and premature death (Brown et al. 2009). According to Finkelhor et al. (2009, p. 407), a strong association exists among youth “between lifetime polyvictimization and mental health symptoms.” Similarly, Whitfield et al. (2003) found that each of three violent experiences children underwent (e.g., physical abuse, sexual abuse, or growing up with a battered mother) resulted in a twofold risk of later being either a victim or perpetrator of IPV (intimate partner violence). In youth, people who experienced all three forms of violence experienced a 3.5-fold increased risk of victimization for women and a 3.8fold increased risk of perpetration for men.

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Studies on Intimate Partner Violence Findings from IPV indicate that lasting and increasing later life effects result from earlier victimization, including cognitive impairment (Cook et al. 2011), continued or escalated harm (Zink et al. 2006), and lifetime consequences (e.g., psychological stress and physical injuries) (Fritsch et al. 2005). The scholarly literature implies that experience earlier in life with multiple forms of IPV results in adverse physical and mental health effects for older adults. Stein and BarrettConnor (2000) conducted a cross-sectional study of 1359 adults aged 50 and older and found that a prior history of sexual assault at any age was associated with increased risk for arthritis and breast cancer in women and thyroid disease in men. A study by Mouton et al. (2010) of over 90,000 women aged 50–79 years revealed that exposure to “verbal abuse only” over the past year affected mental/ psychological health more than did exposure to “physical abuse only.” Baker et al. (2009) found that women aged 50 and older who experienced physical and verbal abuse were less hopeful and more depressed and hostile than were women who had not experienced abuse. Interviews with 459 women aged 55 and older revealed that women with physical assault histories (13%) more often reported symptoms of depression, substance abuse, and post-traumatic stress disorder than did women who did not indicate experiencing prior physical or sexual assault (Acierno et al. 2007).

Polyvictimization by Surrogate Decision-Makers Older adults needing surrogate decision-makers are especially vulnerable because they rely on others for care and/or are unable to advocate for themselves. The issue of elder abuse by surrogate decision-makers has been highly visible nationally, with reports by the Government Accountability Office (2010, 2016) stating that a growing problem exists and damages older adults and their families, but the prevalence is unknown. An article published in The New Yorker by Aviv (2017), How the Elderly Lose Their Rights, described egregious treatment by paid professional guardian (and now convicted) April Parks, a Las Vegas, Nevada, guardian. There are several ways that older adults may have surrogate decision-makers, (e.g., representative payees, bank account signatories, conservatorships, guardianships, quitclaim deeds, and/or trusts). All are legally bound to act in the best interests of the older adult. Powers given to surrogate decision-makers are often vast (e.g., ability to sell a person’s home and personal property, to enter into contracts on their behalf, to clear all medical treatments). In addition, some surrogates charge fees for services that are payable from the bank account of the older adult, which, left unmonitored, has the potential for corruption. While surrogate decision-makers are meant to provide legal protection, there is also a risk that a vulnerable older adult or a decisionally incapable person may fall victim to abuse as a result of having a surrogate decision-maker. Despite this

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situation, there is currently neither reliable data on how many surrogate decisionmakers exist nor data on the outcomes of these arrangements. Many cases of elder abuse go unreported and unabated for multiple reasons: older adults are isolated by perpetrators (especially so because of the powers a surrogate may possess); elder victims may not recognize behavior as abusive, neglectful, or exploitive; they may remain silent because of shame, self-blame, fear of retaliation, and/or further loss of independence; and they may fear loss of the support they receive from the abuser (Acierno et al. 2010). Victims may also feel sympathetic and protective of the perpetrator, especially when the perpetrator is their offspring or other family member and when mutual dependence, substance abuse, and mental illness are involved (Ramsey-Klawsnik 2017; Roberto 2017). Though similarities exist, the definition of polyvictimization emphasizes individuals with special access to older adults and who are engaged in a trust relationship with the older adult that can involve multiple types of elder abuse or be sequential in nature (Teaster 2017). Excluded from the definition of polyvictimization are repetitive acts of one type of abuse, meaning that as long as the repetitive acts involve just one offender, they do not constitute polyvictimization. If repetitive acts involve more than one perpetrator, then these acts constitute polyvictimization.

Older Adult Polyvictims Amidst the Opioid Epidemic Older adults are an important but frequently forgotten generation touched by the opioid epidemic in the United States. Some older adults suffer from multiple chronic conditions and high rates of chronic pain. Opioids and related prescription and nonprescription drugs can be the treatment of choice for these individuals. The opioid epidemic has harmed older adults due to the addiction of their family members and others who rely upon them for money, child care, food, and shelter. Older adults are harmed directly because perpetrators may exploit older adults for their drugs. They are also harmed indirectly because older adults themselves may become addicted to the very drugs that reduce their pain and consequently may be highly susceptible to elder abuse. In late 2017, Teaster, Roberto, Lindberg, and Blancato conducted 4 1-hour focus group interviews with 20 selected representatives from involved stakeholders in four states and counties where deaths from opioids were the highest (Kentucky, Ohio, Virginia, West Virginia). Their goal was to investigate the relationship between increasing high rates of opioid use and elder abuse. Overall, focus group participants regarded that the problem is escalating in scope and severity, estimating a 25–35% increase in drug-exploitation cases. Participants also indicated that when desperate perpetrators had exploited and run through an older adult’s money, drugs, or both, the adults were psychologically and physically abused. In fact, the perpetrators isolated the older adults in their own homes in order to prevent them from helpseeking.

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Section II: Clinical and Sociological Reflections on Polyvictimization Acts of interpersonal violence are linked, with apparent great frequency, to other acts of such violence. Herein seems to lay an essential feature of “polyvictimization.” Acts of interpersonal violence are linked in multiple ways. When one form or type of interpersonal violence (e.g., physical, sexual, emotional, exploitation) is exhibited in any setting (e.g., family home, school, place of employment, nursing care facility, residential facility for people with intellectual disabilities), it is frequently accompanied by additional forms of violence (e.g., see Dong et al. 2004; Burgess et al. 2008; Ramsey-Klawsnik 2017; Teaster et al. 2006). To illustrate, a visitor to a residential care facility observed an irate employee pushing into a shower and slapping a young adult resident who had multiple disabilities. Forensic interviewers subsequently heard from the young man that for many months he had felt repeatedly humiliated, degraded, and intimidated by that employee. Full investigation led to the recognition that multiple residents endured similar and ongoing types of mistreatment inflicted by this employee. It is not unusual in care facility abuse investigations to find that the abusers, be they employees or residents, have targeted multiple victims (e.g., see Ramsey-Klawsnik 2004; Ramsey-Klawsnik et al. 2007). When one bully is able to repeatedly violate others within an environment, there may well be additional abusers, in addition to multiple victims. This is so because the specific environment was not created and/or maintained in ways that prevent, minimize, or prohibit victimization of less powerful by more powerful individuals within it. So, for example, when child abuse occurs within a family, it is not unusual to find intimate partner violence and/or elder abuse as well. Conversely, social service and mental health practitioners have noted that among families brought to their attention due to elder abuse, careful psychosocial assessment and history gathering often reveal evidence of prior or current child and/or intimate partner abuse involving other perpetrators. A case in point: Margaret, age 79, resided in her long-term marital home - a rural, once active but long defunct small family farm. She was widowed and poor. Her two adult sons, Gary and Leo, both unemployed and actively substance-abusing, lived in her home but did not help to support or maintain the home. Margaret’s multiple siblings resided in her home state, but in towns at some distance. She could no longer drive or afford either a car or telephone service. Her closest friend was a neighbor living on her road but over a mile away. Margaret rarely had contact with members of her family of origin, which caused her pain and loneliness. It had been many years since extended family gatherings to celebrate holidays and birthdays had stopped and communication rifts had developed. That occurred when Margaret’s boys were young, her husband was alive and farming and driving, and the family could afford essentials such as a car and a telephone. During her early years of marriage, regular extended family gatherings were a source of great pleasure for Margaret. Then Gary and Leo began acting sullen and rebellious. They refused to go to family get-togethers and spoke about Uncle Gus, Margaret’s brother-in-law, and his doing “nasty stuff.” Piecing together what the boys were willing to reveal with information gathered from her siblings, Margaret

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discovered that Gus was sexually assaulting the children in the extended family at family events. At that time (and sadly, continuing into the present) children who disclosed sexual assault were rarely believed over adults who adamantly maintained their innocence. Furthermore, child abuse services were in their infancy when Margaret faced the realization that her boys had endured repeated sexual assault. Margaret tried discussing this with her younger sister, Rachel (Gus’s wife). Rachel became furious with Margaret and defensive of Gus. Margaret reluctantly decided that the only way to protect her children was to stop attending family events. Years passed with the family feud silently intact. Over time, Margaret’s loneliness for her siblings and nieces and nephews grew. Occasionally, one would stop by her home, which provided a welcome but also sad time to “catch up.” But Rachel never came, and after all, she did not drive and could not independently make the thirty-mile trip. Then “out of the blue,” while Gary and Leo were “sleeping off” a night of heavy drinking, a car appeared in the disintegrating driveway. It was Gus. He came to the front door and told Margaret that Rachel was dying from cancer and wanted to see her. He offered transportation. Margaret’s thoughts raced - she wanted desperately to see Rachel catch-up, apologize, comfort her in her illness, and most of all, have a chance to say goodbye. She wondered if she would be safe in Gus’s car - but then, she reasoned, he was a child sexual offender. There had never been any suggestions of him harming women. Besides, Margaret assumed, she was older now, and surely no one would be interested in sexually assaulting her. With trepidation and also a raging desire to see her dying sister, Margaret accepted Gus’s offer. They drove to the emotional visit at which the sisters cried and hugged and laughed and made amends and said hello and said good-bye. Gus then drove Margaret home. On the way, he pulled off the road into a wooded area. He shoved Margaret out the car into the dirt, with leaves surrounded by trees blocking the view from the road, and violently sexually attacked her. He then shoved her back into his car, drove to her home, and threw her out of the car and to the ground before driving off. Margaret, brutalized and in a state of shock, injured and with torn and bloodied clothing, eventually crawled into her home. Gary and Leo “lit into her.” “Where the hell have you been!” “You are a mess!” “What did you do?” Margaret managed a few words describing the events. Her sons burst into rage, screamed obscenities, called her a stupid, bad mother who never believed or protected them from Gus, and a “jackass” for getting into Gus’s car. They threw things around the room and kicked and broke furniture, terrorizing Margaret and further breaking her heart and her spirit. She stumbled to her bed throbbing with pain, and suffering from contusions, abrasions, and vaginal bleeding. Margaret remained in her bed for two days until she found the strength to walk to her neighbor to seek help. Her friend listened to her, comforted her, and drove her to the regional hospital for medical care.

Clinical Case Analysis This synopsis of an actual case of elder abuse that presented for services (in which all identifying information is concealed) demonstrates a frequently observed mix of current elder and historic child abuse as well as the common mix of multifaceted physical, sexual, and emotional abuse and neglect. Tragically, the violence and dysfunction in Margaret’s family over many years involved multiple victims, perpetrators, and abuse types. Although some members were directly physically and sexually assaulted, all were harmed emotionally and socially by Gus’s abuse of the children as well as the resulting family fracture.

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It is significant to note that Gary and Leo had financially exploited Margaret (further degrading her meager standard of living) for an ongoing period prior to the day that Gus showed up and wreaked further havoc on the household. The emotional abuse and neglect inflicted on Margaret by her adult sons when she revealed what Gus had done demonstrate the dynamic of “cascading abuse.” This form of polyvictimization “occurs when one or more episodes of abuse trigger subsequent, additional forms of abuse inflicted by the same or other offender(s)” (Ramsey-Klawsnik and Miller 2017). Certainly, hypotheses regarding the etiological role of the childhood sexual assault suffered by Gary and Leo in their adult substance abuse and role dysfunction, as well as their exploitation, abuse, and neglect of their mother, would be explored during the course of clinical treatment. It is also clinically of interest, as well as quite sad, that Gary and Leo perceived that Margaret had not believed their childhood disclosures of assault by Uncle Gus and that they carried rage regarding their belief that she did not act to protect them. In contrast, Margaret felt that she had taken the only option open to her to protect her young boys, even at the cost of alienation from her family of origin.

Sociological Analysis Margaret’s story illustrates the multiple powerful ways in which polyvictimization harms people and families and society. But sadly, it is not a unique case. In clinical practice, it is not unusual to hear of multi-trauma, multi-abuse, multivictim, and multi-perpetrator situations within nuclear families, extended families, schools, care facilities, and other social groups. These cases can be quite overwhelming. Perhaps this is one reason why researchers, clinicians, policy-makers, government, and agency leaders have artificially carved interpersonal violence into smaller chunks in attempting to understand, study, prevent, and treat it. We have carved elder abuse into physical, sexual, emotional, neglect, exploitation, and abandonment. In fact, we have carved the whole of interpersonal violence into the subfields in which many of us research, teach, write, and provide clinical or victim services: child abuse, spouse/domestic abuse, disabled abuse, and elder abuse. It is not surprising that this has been the approach – the entirety of the problem of interpersonal violence, people with greater power taking advantage of those with lesser power – is so vast, so overwhelming, and so frightening in its scope and consequences that breaking it into smaller bits to tackle has seemed reasonable. In doing so, however, there remains the risk of losing the interconnections, overlooking the links, missing the obvious in our search for understanding of and effective violence preventions, interventions, and policies. It seems that the rather recent “discovery” and consideration of “polyvictimization” is our attempt to see, in all of its complexity, the diverse bundle of forms and methods and iterations in which some people with greater power harm and intimidate those over whom they can gain control. The recent attention to polyvictimization is a desirable, although overwhelming, initiative. Mentioned above, recognition of polyvictimization began in the

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child abuse subfield. This is not surprising given that efforts to formally address child abuse in the United States began in the 1960s, a decade before our attention to physical and sexual violence against women and two decades before our “discovery” of and attention to elder abuse. Formal recognition of the widespread victimization and trampling of the rights of people with disabilities began in the 1970s with the “deinstitutionalization” movement. There remains today, however, a relative dearth of funding, research, publications, and initiatives to protect people who have disabilities, thus rendering them exceptionally vulnerable to abuse. Related anti-violence movements, such as the rape crisis movement and the civil rights movement, have also been significant initiatives to “right wrongs” and bring increased safety and justice to victims. Each is and has been necessary and profoundly important. It is obvious, however, that the various movements and fields and subfields that have developed to address aspects of interpersonal violence have helped draw attention and understanding away from the bigger picture of “polyvictimization.”

Future Directions for Research and Practice Because there are so few studies on elder abuse and polyvictimization, many possibilities exist. It is also critical to ground studies within theoretical frameworks, with the ecological framework holding much promise for examinations of polyvictimization. Among studies that are the most pressing include studies on combinations of various subtypes of abuse by family members and studies on combinations of various subtypes of abuse by special populations (e.g., surrogate decision-makers, bullies, those who are not-trusted others). Because one type of abuse can lead to another, it is highly possible that one abuse type could begin with a single perpetrator but escalate to include multiple perpetrators. Consequently, understanding differences in polyvictimization by one perpetrator versus polyvictimization by two or more perpetrators is a critical direction for future research.

Key Points • Young polyvictims are likely different from older polyvictims, particularly in regard to physical health and cognitive capacity. • Grounding research in an ecological framework can improve research on polyvictims in later life. • Polyvictims in youth are susceptible to abuse later in life. • It is important to discern ways to prevent the polyvictimization of older adults as well as to intervene effectively and quickly. • There are very few studies of the polyvictimization of older adults and many opportunities for research.

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Summary and Conclusion The interpersonal violence field has begun to address “polyvictimization” as well as victims of polyabuse, initially focusing on child victims and more recently, on older adult victims. Polyabusers – people who engage in multiple types of abuse or harm multiple categories of individuals – have not yet been systematically addressed. The criminal justice field has been required to deal with “serial offenders,” and it is commonly known that bullies and abusers rarely restrict themselves to a single victim. To date, however, there has been inadequate professional attention to abusers who seek to obtain coercive control over potential victims who differ widely from each other, such as children and older adults. To illustrate, it has long been assumed, as it was by Margaret, that a person who sexually assaults children is not interested in committing such offenses against people of other age groups. Many bullies do not limit themselves to only one group or type or age of victim (Hartley 2004; Straus and Gelles 1990). Many take advantage of any available persons, as well as animals, with less power than themselves. We also know that people who engage in one form or type of abuse rarely restrict themselves to harming others only in that single manner, be it via physical, emotional, sexual, or other attack. While some elder abusers may, for example, be motivated to only financially exploit vulnerable older adults over whom they can achieve control, others subject their victims to a variety of abusive tactics and feel entitled to do so. This all points to the fact that polyvictimization is indeed a highly complex and not easily understood phenomenon. It is one, however, well worth studying in our quest to create and protect safety and justice for all members of society, with special attention to the more vulnerable among us – including older adults, people of all ages with disabilities, and children.

Cross-References ▶ Adverse Childhood Experiences: Past, Present, and Future ▶ Integration of the Types of Interpersonal Violence Across the Lifespan ▶ Intimate Partner Violence: Terms, Forms, and Typologies

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevalence of Elder Abuse and Perpetrators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Framework for Studying Perpetrators of Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Personal Characteristics of Perpetrators of Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age and Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Race, Ethnicity, and Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Personality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Substance Abuse and Mental Health Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Relationships Between Perpetrators and Victims of Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Community Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Residential Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interventions for Perpetrators of Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Supporting Care Arrangements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Choosing and Monitoring Appropriate Surrogate Decision-Makers . . . . . . . . . . . . . . . . . . . . . . Expressing Preferences for Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Holding Perpetrators Accountable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recognizing of What Constitutes Elder Abuse and Why It Is Not Ethical or Moral . . . . . . . Specifically Identifying Ageism as a Contributor to Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . Directions for Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Role of Socioeconomic Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Role of Mental Health Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Role of Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Role of Interdependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Role of Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. P. B. Teaster (*) · K. A. Roberto Center for Gerontology, Virginia Tech, Blacksburg, VA, USA e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_91

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Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Research from the most reputable national studies of elder mistreatment indicate that family members are the most frequent perpetrators of elder abuse. Of these family members, many have problems with substance abuse and mental health and are socially isolated. However, perpetrators of elder abuse range from spouses and adult children to professionals in all types of arenas that interface with elders to sweetheart and telephone scammers. In addition, suggestions for next steps in the prevention of those who perpetrate mistreatment as well as suggestions for intervening in the perpetration while maximizing outcomes for both the perpetrator and the victim are provided. Keywords

Perpetrators · Elder abuse · Mistreatment · Prevention · Intervention

Introduction Older adults who experience abuse typically know their perpetrators. Most often, the abuse occurs at the hands of family members including, but not limited to, the victim’s spouse, adult children, grandchildren, nieces, and nephews. Trusted others, those individuals upon whom older adults may rely upon for assistance and services, such as friends and neighbors, paid caregivers, financial advisors, legal guardians, home repair workers, and the like, are also known perpetrators of elder abuse. Outsiders often perceive these alleged perpetrators as primary sources of support for older adults rather than individuals who are causing them harm. In some situations, older adults themselves are the perpetrators, inflicting physical or psychological harm to their caregivers or acting aggressively toward their peers. This chapter focuses on the personal characteristics of known perpetrators of elder abuse and the relationships they have with the older adults they abuse. Abuse perpetrated by strangers (e.g., telemarketing scams, home repair scams, Internet phishing) is also of growing concern, but is beyond the scope of this chapter. The chapter begins with the latest prevalence data on perpetrators of elder abuse available nationally and internationally, followed by a theoretical framework for unraveling the complexities associated with the perpetration of elder abuse. After a discussion of perpetrator characteristics and relationships with elders whom they abuse, the chapter concludes with recommendations for interventions aimed at perpetrators and directions for future research. Within the field, the use of the term abuse versus mistreatment is hotly debated, an issue also beyond the scope of this chapter discussion. For the purposes of this chapter, the terms abuse, incorporating the

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varied types of mistreatment including physical abuse, sexual abuse, psychological abuse, caregiver neglect, and financial exploitation, and mistreatment are used interchangeably and reflect their use in the literature and concepts cited.

Prevalence of Elder Abuse and Perpetrators In the United States, the older adult population (aged 65+) is expected to double by 2030 (Federal Interagency Forum on Aging-Related Statistics 2016). The fastestgrowing segment of the population is persons aged 85+, adults who are at highest risk for needing augmented support or assistance while experiencing physical and/or cognitive changes. These vulnerabilities can leave some older adults unduly susceptible to perpetrators of elder abuse. Three national studies provide findings about the prevalence of elder abuse and identify perpetrators. Laumann et al. (2008) used the National Social Life, Health and Aging Project to query older adults about recent experiences of mistreatment by a family member. Data from 3,005 community-residing participants aged 57 to 85 indicated that 9% of older adults reported verbal mistreatment, 3.5% financial mistreatment, and 0.2% physical mistreatment. A greater percentage of spouse/romantic partners (26.2%) verbally mistreated the older adults than did their children (14.5%), or parents (2.0%). Conversely, a greater percentage of children financially exploited (34.0%) and physically mistreated (24.8%) older adults than did spouses (9.6%, 19.6%, respectively). Parents did not engage in either financial or physical abuse of the older adults. Collectively, the percentage of “others” including ex-spouses, romantic partners, stepchildren, in-laws, and siblings, as well as friends, neighbors, co-workers, and paid helpers, constituted 57.3% of perpetrators of verbal mistreatment, 56.4% of financial mistreatment, and 55.6% of physical mistreatment of the older adults. Odds of verbal mistreatment were higher for women and those with physical vulnerabilities and were lower for Latinos than for Whites. The odds of experiencing financial mistreatment were higher for African Americans and lower for Latino Americans than for White Americans. Acierno et al. (2009) estimated prevalence and assessed correlates of emotional, physical, sexual, and financial mistreatment and potential neglect of adults aged 60 years or older in a randomly selected national sample using random digit dialing across geographic strata. Data from 5,777 respondents revealed a 1-year prevalence of 4.6% for emotional abuse, 1.6% for physical abuse, 0.6% for sexual abuse, 5.1% for potential neglect, and 5.2% for current financial abuse by a family member. One in ten respondents reported emotional, physical, or sexual mistreatment or potential neglect in the past year, with the most consistent correlates of mistreatment being low social support and previous traumatic event exposure. Perpetrators were known to victims and were family members in over half of the cases. In regard to emotional mistreatment, romantic partners/expartners constituted 25% of perpetrators, 18% were children or grandchildren, and the rest were acquaintances. As for physical mistreatment, 76% of

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perpetrators were family members, half of whom had problems with substance abuse, a third had problems with mental health, a third were without employment, and nearly half were socially isolated. For victims who were sexually assaulted, 52% were family members and 40% were spouses. Related to neglect, 28% of partners were neglectful, 39% of children were neglectful, and 23% of acquaintances were neglectful (Acierno et al. 2009). The most recent prevalence study by Burnes et al. (2015) examined past year prevalence of elder emotional abuse, physical abuse, and neglect for households in New York. Similar to that of Acierno, the study used random digit dial sampling and direct telephone interviews. Findings from 4,156 community-dwelling, cognitively intact individuals aged 60 and older revealed a 1.0% prevalence of elder emotional abuse and a 1.8% of physical abuse and of neglect, for an aggregate prevalence of 4.6%. The authors conceded that perpetrators could well be reporting elder mistreatment when answering the study questions. In nearly a third of cases (31.2%), a spouse or partner perpetrated emotional abuse and was over a third of the time (36.8%) the perpetrator of physical abuse. Adult children (29.9%) or home care providers (28.0%) were the most common perpetrators of neglect. Emotional and physical abuse were associated with being separated or divorced, living in a lowerincome household, functional impairment, and younger age. Neglect was associated with poor health, being separated or divorced, living below the poverty line, and younger age (Burnes et al. 2015). With the aging of the world population, elder abuse is gaining recognition across the globe. Lowenstein et al. (2009) conducted the First National Survey on Elder Abuse and Neglect in Israel during 2004–2005 in order to examine abuse and neglect from the perspective of the victim, develop profiles of those at risk, and gather data on the prevalence and severity of various types of abuse. Data were collected through a nationally representative sample utilizing personal interviews of older Arab and Jewish older adults who were 65 years of age and older and living in the community. Findings indicated that 18.4% of the older adults were exposed to at least one type of abuse during the past 12 months, with verbal abuse being the most common form, followed by financial exploitation. Women were more often exposed to physical violence, with physical, emotional, verbal, and sexual abuse and limitations on freedom occurring most often among partners. Financial exploitation was typically perpetrated by adult children. Partners who were perpetrators had more chronic health problems and physical and mental disabilities than those who did not. When children were perpetrators, they were often living with the victims and were unemployed, experienced mental health and substance abuse problems, and were in the process of separation or divorce. A study by Soares et al. (2010) used 4,467 randomly selected women and men from community settings in 7 urban areas in Europe: Stuttgart, Germany; Athens, Greece; Ancona, Italy; Kaunas, Lithuania; Porto, Portugal; Granada, Spain; and Stockholm, Sweden, to understand elder abuse. For people 60–84 years of age, 19.4% experienced psychological abuse, 2.7% physical abuse, 0.7% sexual abuse,

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and 3.8% financial abuse. Across all the countries, spouses/partners were the most common perpetrators of emotional/verbal abuse (34.8%) and physical abuse (33.7%). Friends and acquaintances were the most common perpetrators of sexual abuse (30.3%), and others, such as care staff, were most commonly perpetrators of financial abuse (61.7%). National and international prevalence data paint only a portion of the elder abuse picture. Numerous cases of elder abuse, perhaps as many as 90%, go unreported. Reasons for not reporting abuse include the following: older adults are isolated by perpetrators; older adult victims may not recognize perpetrator behavior as abusive, neglectful, or exploitive; the older adult may stay silent because of shame, selfblame, fear of retaliation, and/or further loss of independence; and an older adult may fear the loss of even the minimal support he or she receives from the perpetrator. Victims may also feel sympathetic and protective of the perpetrator, especially when codependence, substance abuse, mental illness, or a combination thereof are involved (Roberto 2017).

Framework for Studying Perpetrators of Elder Abuse People who are abused, neglected, or exploited experience multiple levels of opportunities and barriers in an attempt to maintain their health and well-being in later life. The Ecological Systems Framework (Bronfenbrenner 1986) and its adaptation by Roberto and Teaster (2017) is particularly useful for understanding elder abuse. This organizing framework includes a focus on the elder victim and four influencing systems (Fig. 1). Within the microsystem are the elder victim and his or her environment. Important are the conditions with which we find the older adults who may be susceptible to perpetrators of elder abuse – income level, chronic illness, mental health issues, and cognitive problems. Found in the mesosystem is the current relationship and the history of the relationship between the victim and the perpetrator. Here may reside answers to why the perpetrator lives with the elder. The exosystem consists of environments that are external to the victim and perpetrator (e.g., APS, community services, law enforcement) that influence how abuse is addressed at the local level. This system unpacks the heavy responsibility of APS as it interfaces with the perpetrators and numerous other agencies and organizations. Finally, the macrosystem comprises broad societal ideological values, norms, and cultural and institutional patterns (e.g., state/federal programs and regulations/policies or a lack thereof). Issues of society attitudes toward older adult victims and perpetrators determine how the problem of elder abuse is addressed. The contextual and broad perspective that this framework permits contributed to significantly increasing the understanding of the complicated issues surrounding elder abuse by perpetrators. Identifying and understanding perpetrators’ personal characteristics and their relationships with their older victims is critical for and central to prevention and intervention efforts.

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Fig. 1 The ecological framework for elder abuse

Personal Characteristics of Perpetrators of Elder Abuse Abuser characteristics play an important role in predicting and preventing elder abuse. Yet, little information is available about the perpetrators of abuse. Much of the research on risk factors and motives for committing elder abuse relies upon small, crosssectional studies that do not differentiate the type(s) of abuse or address how personal characteristics and life circumstances may converge to place perpetrators in situations that heighten the likelihood of their doing harm to older adults. This is not to suggest that persons who abuse older adults are not responsible for their actions – they are – but this points to complexities of individual lives and personal relationships.

Age and Gender Perpetrators of elder abuse range in age from teenagers to older adults. The types of abuse they perpetrate are as varied as those who commit it. Older spouse and partner perpetrators and their victims are often of similar age. Adult children who abuse their parents are frequently middle-aged. The ages of grandchildren who abuse their grandparents are more variable. Young adolescents who engage in abusive behaviors are often being raised by their grandparents, whereas adult grandchildren often seek

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refuge in the homes of their grandparents when they encounter difficult times (e.g., unemployment, encounters with the law) and are looking for help and support. Though studies include the age of the perpetrator as a descriptive variable, little attention has been given to age as a differentiating factor. One exception is a recent investigation of older adult sex abusers and child sex abusers (Browne et al. 2018). Perpetrators of older adult sex abuse were younger than the child sex abusers, indicating that young age may be an aggravating risk factor for this type of offense. Many of the sex abusers of older adults had some previous attraction to older persons or previous offenses, suggesting a prolonged interest in sex offending against older females. They often spend little time thinking and planning their actions, acting quite spontaneously. It is a commonly held belief that men are more frequently the perpetrators of abuse than women, but empirical evidence supporting this claim is limited, and the gender of the perpetrator appears to be associated with the type of elder abuse under investigation. For example, investigations of late life intimate partner violence consistently show that men were more likely than women to be abusers (Gerino et al. 2018). While most studies of financial abuse report that male and female relatives are equally likely to exploit older adults, the MetLife national studies of media reports of elder financial abuse (2009; 2011) revealed that financial abuse was 2.5 times more likely to be committed by sons than by daughters. When sexual abuse of older adults is the focal type of abuse examined, men were more likely than women to be the perpetrators. Males were more commonly offenders of sexual abuse of older family members living in communities and older residents in care facilities (Roberto and Teaster 2005).

Race, Ethnicity, and Culture Perpetrators and victims of elder abuse frequently share the same racial or ethnic heritage. Belonging to a racial or ethnic minority group is a frequently identified risk factor for elder abuse. Early and small-scale studies suggested that this may be because of differing perceptions and beliefs about what constitutes abuse. More recently, race- and ethnicity-based differences in the perpetration of abuse failed to be found in the analysis of national elder abuse prevalence data. Cultural influences may interact with race and ethnicity, as well as acculturation, to influence beliefs about power, authority, and rights within relationships. For example, different perceptions of elder abuse have been found among members of different racial and ethnic Latino groups (Enguidanos et al. 2014). Beliefs about elder abuse may also vary in different types of communities. When Shielding American Indian Elders were asked what it meant to be treated well and poorly by family, they responded that good treatment included “being taken care of, having one’s needs met, and being respected whereas poor treatment was defined as financial exploitation, neglect, and lack of respect” (Jervis 2014, p. 78). Traditional and patriarchal views of the family, economic stressors, and the value placed on selfsufficiency often found in rural environments may inadvertently facilitate elder abuse (Teaster et al. 2006).

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Personality Perpetrators of elder abuse often are viewed by outsiders as charming and attentive to the needs of the older adults whom they abuse and exploit. They exhibit excellent persuasion skills, which allow them to convince older adults that they are worthy of their trust and to gain control over them. Conversely, perpetrators also show a distorted sense of reality, an inability to empathize, a lack of impulse control, and an inability to handle frustration (Anetzberger 2013). Several typologies of perpetrators of elder abuse based on personality and other characteristics have been proposed but have yet to be empirically validated. For example, specific to elder financial abuse, Tueth (2000) described two subtypes of perpetrators. Passive/opportunistic perpetrators were characterized as dysfunctional, psychosocially stressed individuals with low self-esteem and substance abuse problems, whereas active/predatory perpetrators actively sought out vulnerable older adults in order to manipulate them by using threats and intimidation. Through her clinical practice, Ramsey-Klawsnik (2000) identified five perpetrator personality types. Overwhelmed perpetrators were well intentioned and qualified to provide care, but they were stressed, resulting in harm to the older adult. Impaired perpetrators tend to have low intellectual abilities, physical impairment, mental illness, and/or substance dependence, often associated with psychological and physical abuse and neglect when the person is placed in a caregiving role. Narcissistic perpetrators met their own needs by using threats of physical violence so that they could gain control over the older victims’ lives. Exhibiting explosive behavior, domineering perpetrators exert coercive control over older victims. They feel entitled to inflict harm and believe that the victim “deserves” the abuse, employing psychological and physical abuse, and in some cases, sexual abuse, to control victims and resources. Sadistic perpetrators humiliate, terrorize, and inflict pain on older victims; they recognize and enjoy their abusive behaviors. Jackson (2014) proposed a four-class typology of perpetrators that falls within a continuum of malicious intent: Ignorant Abusers who are unable to perform caregiving duties, Reluctant Exploiters whose motives are non-malicious, Ready Exploiters who take advantage of an opportune moment, and Bad Actors whose abusive behavior is premediated and deliberate. DeLiema et al. (2017) also identified profiles of elder abuse perpetrators based on a continuum of malicious behavior: Caregiver, Temperamental, Dependent Caregiver, and Dangerous. Caregivers are lowest in harmful characteristics, whereas Dangerous Perpetrators have the highest levels of aggression, financial dependency, substance abuse, and irresponsibility.

Substance Abuse and Mental Health Conditions Many perpetrators of elder abuse have substance abuse and/or mental health conditions. These perpetrators share a prominent characteristic – they are dependent upon on their older victims. They frequently have a history of intermittent or underemployment (Amstadter et al. 2011), shared residence with their victims (Jackson and

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Hafemeister 2012), small social networks (Amstadter et al. 2011), and involvement with the criminal justice system (Chopin and Beauregard 2018). These characteristics may alter interactions and overall quality of the relationship between potential perpetrators and victims and increase the risk of abuse.

Relationships Between Perpetrators and Victims of Elder Abuse Relationships between older adults who experience abuse and their perpetrators range from an intensely close and long-lasting relationship, as in cases where perpetrators are intimate partners or adult children, to no relationship other than residing in the healthcare facility in which the perpetrator lives or is employed. Perpetrators use multiple tactics, often over extended periods of time, when abusing their older adult victims.

Community Settings The setting of the abuse can provide important clues to the type of perpetrator and the type of abuse. It is commonly accepted that more abuse occurs in community versus facility settings because substantially more older adults live in community settings than facility settings. Additionally, elder abuse occurring in community settings is more frequently investigated by researchers because more older adult respondents are cognitively intact and can consent to interviews and because all Adult Protective Services programs throughout the country can investigate reports concerning older adults living in the community. Intimate Partners. Abuse of a spouse/partner in late life may be long-standing or a recent occurrence within a single relationship that may begin with a new relationship. Spouse or partner perpetrators use coercive tactics, such as isolation, threats, intimidation, manipulation, and violence, to gain and maintain power over their victims. In long-standing relationships, physical violence tends to decline with age. Instead, perpetrators use new or intensified types of psychological and emotional abuse (Teaster et al. 2006). Police reports of partner violence revealed that incidents of abuse and violence where women were perpetrators mainly involved verbal abuse, some physical violence, and limited use of threats or harassment. Abusive behaviors used by men who abused their partners were more severe, invoking fear and control of their female victims. Adult Children. Anetzberger (1989) conducted one of the first studies about perpetrators of elder abuse, which focused on abusive adult offspring. The perpetrators typically inflicted multiple types of abuse upon their frail elderly mothers with whom they had lived for several years. In addition to shelter, adult child perpetrators were often dependent on their parents for financial and emotional support (Jackson and Hafemeister 2012). Underlying the dependency could be addiction to alcohol, pain medications, or recreational drugs; a history of mental or emotional illness; and chronic unemployment. These relationships could become abusive when the older

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parent declines or refuses to provide money or other types of support to a dependent adult child and she or he becomes increasingly desperate. Other Relatives. As with adult children, grandchildren and other relatives who abuse their older family members often depend on them for shelter, money, and emotional support. For example, professionals have expressed concern about the vulnerability for elder abuse within homes where grandparents are raising their grandchildren (Bullock and Thomas 2007). Instances of abuse by grandchildren raised by their grandparents include reports of punching, hitting, throwing objects, stealing money or prized possessions, destroying possessions, and threatening the grandparent with weapons. Grandchildren were also among extended kin (i.e., nephews and nieces, siblings, cousins) engaged in financial abuse of their older relatives (MetLife Mature Market Institute 2009). Family Caregivers. The majority of older adults with functional and cognitive limitations who live in the community receive care from a family member. Most caregivers provide appropriate care for their loved ones and do not harm or hurt them. However, as function and memory decline and dependency on family caregivers increases or becomes more intense, the stress, strain, and burden of providing care for a loved one often escalate and can lead to potentially harmful or abusive behaviors. Well-intended caregivers often report the use of psychologically aggressive and physically abusive caregiving strategies, while other caregivers may be neglectful in their caregiving duties. It is not uncommon for abusing family caregivers to inflict multiple forms (i.e., polyvictimization) of elder abuse on their care recipients. As an example, some caregivers of older relatives with Alzheimer’s disease use violence as a conflict resolution strategy. Verbally abusive tactics (e.g., shouting, insulting, or swearing) are reported more frequently by caregivers than are physical strategies (e.g., grabbing, hitting) (Yan 2014). In some instances, abusive behaviors by persons with dementia toward their family caregivers may provoke abuse behaviors by some caregivers. Depressed caregivers were more likely to engage in violent behavior than were those who were not depressed, and caregivers who abused alcohol and who were providing care to violent older adults with dementia were more likely to engage in violent behavior than caregivers who did not abuse alcohol. Also, compromised cognitive status of family caregivers may contribute to potentially harmful and abusive behaviors and adversely influence the quality of care provided to older relatives (Roberto and Deater-Deckard 2018). The relationship between abusive family caregivers and their older relatives with dementia is often complex and fueled by issues of control, dependence, and interdependence. For example, older husbands often blamed persistent and increased stress for their use of violent, abusive, and neglectful behaviors to manage the care of their wives with Alzheimer’s disease (Roberto and DeaterDeckard 2018). Adult child caregivers who are abusive are frequently dependent on their parents for housing, financial assistance, and emotional support (Jackson and Hafemeister 2012) – needs that arose due to drug and alcohol addiction and chronic unemployment (Jackson and Hafemeister 2014). Cultural values and

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normative expectations also shape perceptions about caregiving and beliefs about what constitutes abusive behavior (Moon and Benton 2000). For example, in cases of financial abuse, adult children, grandchildren, and other relatives with caregiving responsibilities used the older adults’ money to which they believed they were entitled (i.e., saw as their inheritance), to meet their own needs or desires rather than to provide care for their family members (Metlife Mature Market Institute 2011). Trusted Others. Most persons in positions of trust initially extend helping hands to the older adults, but some gradually appear overcome by greed. For example, trusted professionals (e.g., financial professionals, attorneys, fiduciary agents; in-home caregivers) collectively are most likely to be perpetrators of financial elder abuse than are other categories of perpetrators, including family members (MetLife Mature Market Institute 2009). They often believed that, in return for providing assistance and care, whether needed by the older person or not, they were due continual compensation (e.g., money, possessions). For instance, most allegations of abuse by guardians for adults involved financial exploitation and misappropriation of assets (Government Accounting Office 2010). Guardians exploited the protected persons for whom they were responsible by engaging in schemes that financially benefited them but were financially detrimental to the person under their care.

Residential Settings Over 1.4 million vulnerable adults in the United States resided in a nursing home in 2014 (Center for Medicare and Medicaid Services 2015). Most residents had at least a moderate level of cognitive impairment (61.4%) and four or more functional impairments (63.1%). An additional 835,200 persons were living in licensed residential care communities, which provide residents with room and board, around-the-clock on-site supervision, and help with personal care tasks (e.g., bathing, dressing) and medication management. Almost 40% of these residents have a diagnosis of Alzheimer’s disease or other dementias. Thus, older adults who need to live in care facilities are vulnerable to abuse at the hands of the individuals who care for them as well as their peers with whom they see and interact daily. Staff. The National Ombudsman Reporting System logged 15,444 complaints in FY 2016 that involved abuse, gross neglect, or exploitation (Administration for Community Living n.d.). Of these, approximately 25% were for physical abuse, 18% were for verbal or psychological abuse, 16% were for gross neglect, 9% were about financial exploitation, and 7% were for sexual abuse. A state-wide survey in Michigan found that families who reported that their relatives were subjected to at least one incident of physical abuse by nursing home staff identified physical abuse (e.g., forced use of restraint (forced feeding, toileting)), physical mistreatment (e.g., hitting, beating, kicking), and sexual abuse as the most frequent types of abuse experienced by their loved one (Schiamberg et al. 2012).

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Work-related stressors have been associated with the perpetration of elder abuse by nursing home staff. Staff members who abuse residents often report poor job satisfaction (i.e., thinking of quitting), perception/belief that residents are “like children,” strong feelings of burnout, and high levels of conflict with residents (Pillemer and Moore 1989). Behavioral problems frequently associated with dementia (e.g., provocative verbal or physical outbursts) were a significant predictor of physical abuse by staff (Schiamberg et al. 2012). Some researchers have argued that perpetrators may seek employment in longterm care settings in order to gain access to vulnerable women, suggesting that being in a position of power and control over residents enable them to perpetrate with relative impunity in many circumstances. Staff who perpetrate sexual assault often target older women with cognitive impairments, as these women are less likely to be viewed as credible. As a result, the member of staff may be more able to hide, deny, or otherwise cover up his or her actions (Fileborn et al. 2018). Residents. Resident-on-resident abuse (RRA) in nursing homes is defined as “negative and aggressive physical, sexual or verbal interactions between long-term care residents that in a community setting would likely be construed as unwelcome and have high potential to cause physical or psychological distress in the recipient” (Rosen et al. 2008, p. 78). About one-fourth of resident-to-resident abuse involves sexual or physical abuse (Administration for Community Living n.d.). One of the first studies to uncover resident-to-resident abuse found that the most frequent perpetrator of sexual abuse was a facility resident (Teaster et al. 2000); the abuse involved instances of sexualized kissing and fondling and unwelcome sexual interest in an older female resident’s body. More recently, the phenomenon of bullying of residents by other residents has come to light as a form of elder abuse. Resident-to-resident bullying is generally through verbal assaults rather than physical ones. Apparent gender differences exist related to how resident perpetrators typical bully others. Men tend to use more direct forms of bullying, such as verbal insults, whereas females use more indirect or passive-aggressive behaviors, such as gossiping and spreading rumors (Bonifas and Frankel 2012).

Interventions for Perpetrators of Elder Abuse It is common practice throughout communities nationwide to approach elder abuse from the victim’s perspective. Older adults are warned about the potential for abuse and provided strategies to prevent becoming victims. Interventions, in the form of information or resources, are in place for older adults who experience abuse to help them manage their situation or eliminate contact with an abuser. To address the complexities of elder abuse, it is highly important to move beyond a historical focus on victims and incorporate strategies that also focus on perpetrators. While this approach to intervention is still nascent, a few strategies and considerations seem viable.

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Supporting Care Arrangements Because most older adults live in community settings, the bulk of interventions should be focused on the home situation. Burnes (2016) suggested that if more than one person could live with an older adult, his or her presence might serve to mitigate abuse. In the ideal situation, perpetrators who are overwhelmed caregivers would have 24/7 in-home support available to them that would reduce, and possibly eliminate, encounters with the justice system because their lack of expertise or abilities create a situation in which they unwittingly neglect older adults who rely on them for care. Interventions of this type would require that support received for caregivers of older adults extends beyond other family members to members of their community, such as volunteer organizations and faith communities. Similarly, care facility settings should uniformly reduce staff-to-resident ratios so that staff has enough time to provide care for residents and respond to their unique needs. In addition, hiring and training staff appropriately and periodically will help them better understand the needs and behaviors of the residents and develop strategies for providing person-centered care. Enhancing the work environment and relationship between staff and residents will contribute to the retention of knowledgeable, caring staff and ultimately reduce the risk of abuse for residents.

Choosing and Monitoring Appropriate Surrogate Decision-Makers Older adults needing surrogate decision-makers are especially vulnerable because they rely on others for care and/or are unable to advocate for themselves. The issue of abuse by surrogate decision-makers has recently been highly visible nationally, with reports by the Government Accountability Office (2010; 2016), recent testimony before the US Senate Committee on Aging and Social Security Administration (Teaster, 18 April 2018), and a flurry of media attention, in particular an article published in The New Yorker by Aviv (2017) entitled “How the Elderly Lose Their Rights.” Very little is known about the scope and frequency of abuse by surrogates, but with a rising older adult population, it is, now more than ever, important to know the identity of the surrogates and, just as important, to support them in their efforts to assist the older adults and to monitor their conduct in order to do so. There are multiple opportunities for intervention, including but not limited to family table discussions to incorporating these discussions in encounters with healthcare professionals and members of the clergy.

Expressing Preferences for Care Making plans for future care is another way to intervene in the perpetration of the abuse of older adults. Older adults need to discuss their preferences for care and care provision with families and friends so that they are prepared to act should the need

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for assistance arise. Care provision should not fall to one person or be a remedy for a family member who is unsuccessful in other arenas in his or her life. Conducting a discussion with those who might be 1 day providing care may prove to be an effective and preventive intervention before circumstances become dire. Such preferences may be articulated through a recording as simple as a video made on a mobile phone, written in a values history, or executed more formally in advance care documents (e.g., power of attorney for finances and healthcare, advance directives).

Holding Perpetrators Accountable For far too long, perpetrators of elder abuse who committed crimes were not held accountable or were held lightly accountable, either because legislation did not contemplate evidentiary issues of such crimes or because victims were more often blamed for the abuse than were perpetrators. To address this issue, many states have enacted enhanced penalties for the abuse of an older person. So too, courts have recognized that older adults can and should have accommodations in order for them to participate. Across the country, elder courts have developed in order to bring to justice perpetrators who have abused older adult victims. It is imperative that courts and associated bodies make accommodations for older adults to appear in court so that justice can occur more easily for all age groups, not just for those who can walk into court.

Recognizing of What Constitutes Elder Abuse and Why It Is Not Ethical or Moral A burgeoning population of elders and a concomitant need for caregivers, particularly for persons in advanced old age, is one impetus for a societal recognition of elder abuse and the need for effective prevention and intervention efforts. Another impetus has been the recognition that stealing from older adults costs all of society, not just an older person (MetLife 2009). Barely addressed and highly underfunded less than three decades ago, important legislation – notably the Elder Justice Act of 2010 – has permeated not only federal and state government but also broader society. Equally as important has been the expansion of celebrations of World Elder Abuse Awareness Day, the brainchild of elder abuse researcher and advocate Dr. Elizabeth Podnieks of Canada. Since its first observation in 2012 at the United Nations in New York, this event, held annually on June 15th, has garnered worldwide attention at meetings and conferences and raised visibility of elder abuse around the world.

Specifically Identifying Ageism as a Contributor to Elder Abuse Fear of growing older, expressed in ageism, has implications, among other things, for the glacial pace of enactment and funding of legislation concerning crimes

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against older adults, and reflects a tacit acceptance and tolerance of the abuse of older adults (i.e., the “I don’t blame him for acting that way” attitude about abusive caregivers). The growing understanding that mistreatment of older people robs society of its resources both now and for the future is an important driver of social awareness and change of regarding the issue and problem of elder abuse. In particular, a scholarly and practical focus on elder financial exploitation has proven to be a rallying point against which ageism can be combatted and elder abuse reduced.

Directions for Future Research A field of inquiry now approaching 40 years, the phenomenon of elder abuse is replete with many important directions for future research. The purpose of this chapter was to highlight both the past and the future for research and practice, especially concerning the perpetrators of elder abuse. A challenge to research is that far less is known about perpetrators than victims; both administrative data and primary data are lacking. Gathering data about perpetrators is quite challenging. Convicted perpetrators are rightly afforded special protections – protections that can impede or halt the progress of research entirely. Research on perpetrators is likely not for the faint of heart, but amassing an understanding of perpetrators can inform important prevention and intervention efforts and should proceed with alacrity.

The Role of Socioeconomic Status Particularly as it concerns health throughout the life course, the role that socioeconomic status (SES) plays in the perpetration of elder abuse is an untapped and important area of inquiry. A historic determinant of overall health, inquiries into SES are necessary to illuminate pathways to clarifying the perpetration of elder abuse. Various and creative influencers (better healthcare or the presence of a mentor) or access to educational opportunities (access to post-secondary education) may prove to be significant interventions.

The Role of Mental Health Status Many perpetrators of the abuse of older adults are persons who have suffered from either adult-onset or lifelong (and frequently unaddressed) mental health problems. Untreated, the mental health problems can affect the lives with whom the adults interact, often leaving older people vulnerable to abuse. It is especially crucial to identify and address the mental health needs of older adults and their caregivers sooner than later so that elder abuse is prevented before mental problems contribute to its occurrence.

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The Role of Substance Abuse The role of substance abuse, in particular the effects of the opioid epidemic now plaguing much of the United States, in the perpetration of elder abuse requires immediate and deeper investigation. While there are anecdotal reports that the opioid crisis is exacerbating the abuse of older adults, no published data exist at present that have established the connection. Sorely needed are both cross-sectional and longitudinal studies to determine the influence of these and other drugs on the abuse of older adults.

The Role of Interdependence Research has identified interdependencies between perpetrators and victims, particularly when the elder is in need of care. Challenges associated with caregiving can trigger potentially harmful or abusive behaviors from even well-intended caregivers. It is likely that various subtypes of abuse may have different sequelae, depending on the victim-perpetrator relationship, individual characteristics, and surrounding context. Research is needed to uncover patterns among these variables in order to identify what triggers “harsh caregiving” or care that is psychologically, emotionally, or physically hostile, lacking in warmth, and abusive when severe or chronic (Roberto and Deater-Deckard 2018, p. 607) to develop interventions to reduce the propensity for abuse under stressful situations.

The Role of Education One of the ways to prevent abuse of older adults is to reduce the number of potential perpetrators. As with other public health interventions, prevention of the problem may well start in early childhood. Attitudes and behaviors toward older people modeled appropriately will, theoretically, dispel the specter of ageism and promote the right treatment of older people, thus minimizing occasion to abuse. Longitudinal research is needed to examine the role of consistent, research-based education about aging as well as “educational booster shots” modeling right behavior and teaching units on the topic at elementary, secondary, and collegiate levels.

Key Points • The Ecological Framework and the Contextual Theory of Elder Abuse hold promise for understanding the phenomena of elder abuse. • Both men and women perpetrate elder abuse, although men are more often the perpetrators of certain subtypes, such as sexual abuse, than are women. • Personality typologies can be associated with the type of abuse perpetrated. Perpetrators with a deep need to control or who are sadistic are often more abusive and dangerous than are other personality types.

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• Substance abuse by perpetrators may exacerbate a tendency to abuse older adults. • Dependencies between perpetrators and victims may result in heightened susceptibility to elder abuse. • Older adults in care facilities are extremely vulnerable to elder abuse because of their increased dependence on others to provide care for them. Staff members of facilities may “cover” for abuse caused by other staff members.

Summary and Conclusions To conclude, elder abuse is a growing problem because of the sheer increase in numbers of older adults. To be sure, more people are aware of the problem than ever before due to the consistent efforts of researchers and practitioners. The past 10 years have seen the metamorphosis of state and national laws to address the problem as well as the gradual institution of World Elder Abuse Awareness Day, now held annually around the world. Much of the past 40 years of research and intervention into the problem has focused on the victim. It is time to widen the lens of research to perpetrators. Prevention and intervention efforts that address reasons why people perpetrate elder abuse can have a high payoff, ultimately reducing the number of people who became perpetrators and the number of older adults who experience abuse.

Cross-References ▶ Caregiving and Elder Abuse: A Complex Relationship ▶ Intimate Partner Violence in Later Life ▶ Poly-victimization: The Co-occurrence of Intimate Partner Violence with Other Forms of Aggression ▶ Recognizing the Trauma Experienced by Community-Dwelling Older Victims of Financial Abuse Perpetrated by Trusted Others ▶ Systems Responses to Older Adult and Elder Abuse

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Background: Definitions and Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Emergence of Elder Abuse as a Problem Requiring a Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Systems Response: Philosophy and Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Identification of Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Older Adult Abuse and the Health Care System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adult Protective Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Aging Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Domestic Violence and Victims’ Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Criminal Justice and Legal System Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A Multidisciplinary Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Elder abuse is a human rights and public health issue that requires interventions that will increase safety and improve quality of life for older adults who experience abuse, their families, and their communities. This chapter describes how the aging, health, and criminal justice systems have established ways to prevent elder

This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. J. S. Ernst (*) Wayne State University School of Social Work, Detroit, MI, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_92

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abuse and to intervene when it occurs. The strategies include adult protective services, long-term care ombudsman, domestic violence prevention and intervention, aging, health and victim services. The philosophy and theoretical orientation behind each strategy differ. The chapter also will address the efforts to create a wide-ranging response to elder mistreatment that relies on cooperation among different service systems, which have varying roles in response. The chapter also addresses the role of laws and public policies in shaping these systemic responses. A challenge is that the majority of interventions to address elder abuse lack solid research that demonstrates their effectiveness. Keywords

Elder abuse · Domestic violence · Financial exploitation · Neglect · Protective Services · Neglect · Self-neglect

Introduction The abuse of older adults is a human rights and public health issue that requires interventions that will increase safety and improve quality of life for the older adults who experience abuse, their families, and their communities. The responses to elder abuse encompass health, aging, social services, and the criminal justice systems. This chapter describes the ways in which the aging, health care, and the legal/ criminal justice systems in the United States work to prevent elder abuse and to intervene when it occurs. The “systems response” to older adult and elder abuse depends on the nature of the abuse, the characteristics of the victim and the perpetrator and their relationship, and where and how the abuse is recognized and subsequently reported. Over the past 40 years, advocates, professionals from health, law, and social services systems, and older adults and their families have worked to create a more inclusive and wide-ranging response to elder mistreatment that relies on cooperation among different service systems (Ernst and Brownell 2013). A human rights perspective posits that all people possess fundamental rights including the right to live free from abuse, and to live in a world where their selfdetermination is respected (Ife 2008). Everyone ages and most people live into old age, even if the definition of “old” and what it means to be old has shifted with the aging of the population. While the differences in how old age is experienced are vast, old age brings changes in physical abilities, increased challenges with acute and chronic diseases, and, for some, deterioration in cognitive abilities and mental acuity. Increased longevity has focused attention on the need to create opportunities for people to age in the most meaningful and health-filled ways as possible, and not to see old age as a time of inevitable decline. Elder abuse is also a public health concern that requires a public health response. A public health response involves efforts made on a system-wide level, such as a national level, to determine prevalence, educate the public, conduct research, and develop effective means of prevention and other system-wide responses (Hall and Teaster 2018).

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This chapter provides an overview of how the aging, social services, health and mental health, and criminal justice systems respond to older adult abuse. It addresses the origins and evolution of how those systems came to address older adult abuse, describes the current structure and proposes what needs to happen going forward. Following a discussion of definitions and prevalence, this chapter describes how older adult abuse is identified in the community because the recognition and reporting of abuse activates the type of response. This section addresses the roles of multiple professionals and service settings in recognizing and reporting elder abuse, and includes a discussion of screening tools. Because many older adults are in regular contact with the health care system, this chapter next focuses on the response of the health and medical community in identifying and responding to abuse and neglect. Health care workers from visiting nurses to emergency responders to primary care physicians have responsibility to report suspected elder abuse to adult protective services and to deal with health consequences of elder abuse. The next section describes Adult Protective Services (APS), the system designed to respond to the abuse of older adults. The chapter then examines the aging services system, which was formed after the passage of the Older Americans Act in 1965. Many older adults who are abused, mostly older women, come into contact with organizations providing services to victims of domestic violence and sexual assault. These services can be a part of, or at least they interact with, the legal system. Following the discussion of victims’ services, the chapter addresses the response of the legal system to older adult abuse. This includes the civil, criminal, and judicial systems. Because responding to the abuse of older adults requires many different types of expertise and knowledge, multidisciplinary approaches are recognized as best practices in dealing with complex situations. The chapter concludes with the discussion of models for multidisciplinary responses that bring together practitioners from different fields.

Background: Definitions and Prevalence Discussions of the abuse of older adults are generally subsumed under the term “elder abuse.” No single accepted definition of “elder abuse” exists. The World Health Organization (WHO) defines it as, “a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person” (World Health Organization 2017, para. 1). Different types of elder abuse include financial, physical, psychological, and sexual abuse by a perpetrator or perpetrators. Older adults may also experience intentional or unintentional neglect from formal or informal caregivers. Polyvictimization, the experience of being the victim of more than one type of elder abuse, is also common (Ramsey-Klawsnik and Miller 2017). Most definitions of elder abuse include the concept of a “trust relationship,” which excludes crime perpetrated by strangers from the definition of elder abuse. Trust relationships

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are characterized by an expectation of care due to the older adult’s vulnerability or needs or a relationship where there is an expectation of respect and affection due to marriage or filial or familial ties. The trust relationship can extend to formal relationships with paid caregivers, attorneys, and financial planners, among other professionals (Bonnie and Wallace 2003). The definition of “older person” also depends on context and program. In the United States, the programs and benefits available to older adults depend on age defined by legislation; for example, programs available under the Older Americans Act are reserved for adults aged 60 and older. In contrast, the National Clearinghouse for Abuse in Later Life (NCALL), which looks at the intersection of domestic violence, sexual abuse, and elder abuse, defines abuse in later life as “the willful abuse, neglect, or financial exploitation of an older adult who is age 50+ that is perpetrated by someone in an ongoing relationship (e.g., spouse, partner, family member, or caregiver) with the victim as well as sexual abuse by any offender, including strangers” (Brandl 2016, p. 7). After age 50, the economic peril for women increases because they are too old to have dependent children and too young for social security and other age-related benefits, and many older women have depended on their husbands for support all their adult lives. Estimates of prevalence of elder abuse vary by the definition of abuse used, population examined, the geographic area studied, and the method used to count. A population-based study in the United States found that an estimated 1 in 10 older adults have been mistreated (Acierno et al. 2010). A meta-analysis of prevalence studies conducted worldwide indicates that elder abuse appears to affect 1 in 6 older adults, which is roughly 141 million people (Yon et al. 2017). There is also discrepancy between reported and unreported cases; a New York State study that revealed only 1 in 24 cases of elder abuse were reported to authorities (Lifespan of Greater Rochester Inc., Weill Cornell Medical School of Cornell University,, and New York City Department for the Aging 2011). The number of people who will experience abuse in later life is projected to increase dramatically with population aging (Pillemer et al. 2016). The consequences of older adult abuse and evidence about protective factors also compel us to examine and improve systems responses. For example, a longitudinal study indicated a strong relationship between elder abuse experienced within the past year and negative emotional and physical health 8 years later. This study also showed that social support mitigated impact of elder mistreatment and other negative outcomes, highlighting the importance of helping older adults nurture and maintain family and social ties in order to prevent social isolation (Acierno et al. 2017). Given the prevalence and consequences and an older adult population that is growing in number and diversity, the abuse of older adults must concern us all (Hall and Teaster 2018). However, the public’s response to elder abuse has tended to be characterized by hopelessness in the face of a difficult and seemingly intractable problem, with older adults imagined as helpless and without agency and selfdetermination (Volmert and Lindland 2016). Although experts conceptualize the problem as something that can be addressed, strong research evidence on whether the interventions to address elder abuse are effective is scarce. Another challenge is

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the varied and complicated needs of the older adults who experience abuse. Working with them requires skill in engagement, assessment, and treatment and also knowledge of resources and ability to engage in multidisciplinary work (Yonashiro-Cho et al. 2017). The growth and diversity of the population of older adults means that we must consider how the aging process and life course experiences affect health, cognition, social relationships, and opportunities. What we understand as “old age” may encompass 30 plus years for some; the recognition of this helps us to see need for a variety of responses that depend as much on the person’s health, functional, and cognitive status as they do on the numerical age of the older adult. This chapter recognizes the interrelationships of the systems that respond to older adult abuse, even if the causes and consequences of abuse vary by the type of abuse and the characteristics of the older adults and the perpetrators of the abuse. The response to older adult abuse is also shaped by differences in how “elder abuse” is understood between and within different geographical, racial, and ethnic groups (Roberto et al. 2015).

Emergence of Elder Abuse as a Problem Requiring a Response Addressing elder abuse “is a complex issue that often requires a multifaceted policy response which combines public health initiatives, social services programs, and criminal law enforcement for abusive behavior” (Colello 2017, p. 2). Each state in the United States has set up systems and programs to prevent and respond to the problem of adult maltreatment. These include law enforcement, protection and advocacy systems, long-term care ombudsman programs, and Adult Protective Services. While many of the systems responses to older adult abuse are state and localitydriven, legislation and funding from Federal government has influenced the structures that are put into place. And, while action to address elder abuse emanating from the Federal government has increased over the past 50 years, the need to improve systems at all levels to better respond to older adult abuse in ways that are empowering and involve older adults as active participants in deciding the best solutions to their problems remains. Examination of evolution of services and supports over the past 50 years reveals how the understanding and response to abuse of older adults has shifted. Both the aging services systems and Adult Protective Services systems, discussed in more detail below, resulted from policy changes at the federal level in the 1960s (Yonashiro-Cho et al. 2017). Attention to elder abuse as a national issue was driven by a series of Senate hearings in the 1970s and 1980s. The need for greater research attention to elder abuse to make it congruent with family violence and child abuse and neglect research in the 1990s resulted in the establishment of an expert panel by the National Research Council. The panel’s report defined “elder mistreatment” and made a series of research recommendations. The Elder Justice Act (EJA) was first introduced in 2002 and passed as part of Patient Protection and Affordable Care Act

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(ACA) in 2010. It provided the first dedicated federal funds for APS programs; although funds were never appropriated. After the passage of the EJA, the Administration for Community Living (ACL) became the federal home for Adult Protective Services (Bobitt et al. 2018). The passage of the EJA stimulated efforts to improve federal action with respect to elder abuse, including the formation of the Elder Justice Coordinating Council (EJCC), which is chaired by the Secretary of the Department of Health and Human Services. The EJCC includes the U.S. Attorney General as a permanent member plus representatives from 12 federal departments, agencies, or entities that have any sort of administrative responsibility for abuse, neglect, and exploitation of older adults. These agencies include the ACL and the U.S. Department of Justice (DOJ), which has strengthened the response of the justice system to the abuse of older adults. The EJCC reports to Congress every 2 years to recommend legislation or other activities at the federal level (Colello 2017). Knowledge of the evolution of services in each sector helps to shed light on the challenges faced by the various systems and suggests ways moving forward.

Systems Response: Philosophy and Approach The systems that respond to older adult abuse vary in philosophy and approach. “Elder abuse” is understood in different ways by the professionals who respond to it and the general public who are asked to support and make use of these responses. For example, some have argued that a biomedical approach to defining and treating elder abuse has missed the “voice” and opinions of older adults who are affected, sometimes adversely, by the policies and programs put into place (Harbison 2016). The public’s limited understanding of what is meant by “elder abuse” may impede development of comprehensive solutions to problems (Volmert and Lindland 2016). Providers must understand the different systems so they can work together, and not at cross purposes, for the benefit of the older adults. For example, increased attention to elder abuse as a criminal justice issue brings more older victims into contact with programs set up to serve victims of crime and domestic violence, who must then respond to the unique needs of older victims (Jackson 2017). Scholars and advocates across disciplines have worked together to develop collaborative approaches to addressing the abuse of older adults, which involves understanding how these different systems have responded (Brandl et al. 2006; Nerenberg 2008). The systems also vary by the elder abuse-related services performed on a continuum from prevention to intervention in the most egregious cases. Examples of prevention include elderly health and well-being initiatives that allow older adults to remain independent as long as possible (Scharlach 2012); educating community providers and others who come into regular contact with older adults (e.g., postal workers) to be aware of the signs of elder abuse and where they can refer people for help (Kaye 2017); and addressing the causes of social isolation (Portacolone 2017). Systems also vary by the type of elder abuse that they address. For example, the financial services sector has responsibility to put safeguards in place for older adults

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and to identify and refer cases of financial exploitation and fraud to the appropriate authorities (Stiegel 2012). The domestic violence network addresses intimate partner abuse and domestic violence and responds to abuse of older adults (primarily women) through empowerment models that focus on safety planning and navigating the legal system. Most of the situations that Adult Protective Services deals with address the neglect or self-neglect of vulnerable older adults. All systems must work with the criminal justice system, which has responsibility to hold perpetrators accountable for the crimes that they have committed. All of the systems that respond to the abuse of older adults must build awareness of the impact of inequality, diversity, and life course trauma into their service models. The concept of intersectionality helps focus on how old age interacts with other identities including race, ethnicity, sexual orientation, immigration status, and disability (which affects who is caring for the older adults and whether or not they are living in an institution). More attention to and research on elder mistreatment in underserved populations is needed. While race and ethnicity alone do not put older adults at risk for abuse, race and ethnicity, along with other factors, can signal the existence of cultural and social dynamics that might put particular groups at risk for abuse (Jervis et al. 2016).

Identification of Elder Abuse Encounters with professionals provide an opportunity to recognize and address elder abuse. Because older adults have more contact with the health care system than almost any other service setting, health care personnel in emergency rooms, primary care clinics, long-term care settings, and home health care must be able to identify suspected abuse or neglect of older adults. Professionals in other settings, such as social service agencies, law enforcement, banks and other financial services firms, and recreation and leisure centers, to name a few, must be able to identify the signs of elder abuse and make appropriate referrals. Mandatory reporting laws exist in every state but New York. Adult Protective Services, described later in this chapter, receives these reports for community dwelling adults in most states and the longterm care ombudsman or state health departments receive reports of abuse in facilities such as nursing homes. The heterogeneity of abuse makes its identification challenging. The different subtypes of physical abuse, sexual abuse, emotional or psychological abuse, neglect, abandonment, and financial or material exploitation have different risk factors and symptoms. The symptoms of abuse, such as bruises for physical abuse or decubitus ulcers (bedsores) for neglect, have multiple causes and do not necessarily signal that elder abuse has occurred (DeLiema et al. 2016; Wiglesworth et al. 2009). Professionals can use screening tools to recognize that an older adult is at risk of abuse; however, more work is needed on their development. While at present, there is “no gold standard for elder abuse screening tools” (National Center on Elder Abuse 2016), over the past 20 years, considerable effort has been expended on developing screening tools that will assist in identification of and response to abuse.

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The difficulty in screening for something as multi-faceted as elder abuse complicates the development of tools. Instruments must be both sensitive (the measure can correctly classify cases of true elder abuse and neglect) and specific (the measure or instrument can correctly classify cases that are NOT elder abuse). According to Pickering et al. (2017), “there is reason to favor high sensitivity (true positives) over specificity (true negatives)” because of the risk of the disruption that a false accusation of elder abuse would result in (p. 43). The American Medical Association recommends screening for elder abuse, but balancing the benefits and harms of screening is not always easy. The benefits of screening include early detection and a pathway to stop or ameliorate abusive situations; however, the downside of screening cannot be discounted. The existing response system, anchored by Adult Protective Services, is overwhelmed in many communities and increased screening without a concomitant increase in the resources needed to investigate, confirm, and address the situation will not result in additional protection for older adults (Dong 2015). Examples of instruments used include the four-question Elder Abuse Suspicion Index that was developed to increase the ability of physicians to detect and report elder mistreatment (Yaffe et al. 2008) and has been used in an Administration for Community Living (ACL) funded study to increase identification and reporting in Texas (Administration for Community Living 2017); it has also been adapted for use by police in Connecticut (Kurkurina et al. 2018). The Qualcare scale has been developed for use in home health care (Pickering et al. 2017). Instruments designed for health settings can improve identification and reporting by medical personnel.

Older Adult Abuse and the Health Care System The majority of older adults have regular contact with the health care system, and elder abuse is associated with higher medical costs and intensive use of health care services, including an increased rate of nursing home placement found in older adults who become involved with the Adult Protective Services systems (Dong and Simon 2013; Lachs et al. 2002). This system ranges from care provided in physician’s offices and outpatient settings to emergency rooms and the hospital. It also includes services provided in the home by visiting nurses, physical and occupational therapists, and home health care workers. The dentist’s office is another setting were elder abuse can be identified which can be helpful because older adults often have regular contact with oral health professionals (MacDonald et al. 2017). However, doctors and other medical personnel have not always recognized elder abuse and, if recognized, they have not always reported it even though they are subject to mandatory elder abuse reporting laws in most states. Research has identified some effective short-term interventions that have increased their ability to recognize the signs and symptoms of abuse; in a literature review, Moore and Brown (2017) identified five evidence-based studies that showed good short-term results with interventions that aimed to educate medical personnel about elder abuse. Elder abuse may be identified and addressed in emergency rooms. However, emergency room physicians and personnel do not always detect or report abuse; a

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study of two Illinois emergency departments noted the failure to report two-thirds of the incidents of severe physical abuse that presented (Friedman et al. 2014). Case studies of older adults brought to emergency rooms provide an example of the challenges for emergency room personnel in identifying and documenting elder mistreatment while keeping in mind the need to look out for the well-being of the older adult. The exploration of the family and living situations of two “comparable” cases of older adults who exhibited severe bedsores and dehydration revealed that the older adults involved were receiving very different care, with one of the adults actually “neglected” and the other not (DeLiema et al. 2016). In addition, emergency room personnel are not always equipped with the proper knowledge and skills to identify and then refer abused older adults to Adult Protective Services or other appropriate agencies. The development of consultation services to improve identification of elder abuse and provide assessment and treatment for potential abused older adults in emergency departments would assist in providing better responses in emergency rooms (Rosen et al. 2018). The abuse of older adults by both staff and other residents also occurs in nursing homes and other long-term care settings. “Cascading abuse” occurs when incidences of abuse, such as one resident harming another in a long-term care setting, leads to further maltreatment if others in positions of trust do not respond appropriately (Ramsey-Klawsnik and Miller 2017). Long-term care ombudsman programs, part of the aging services network described below, respond to complaints about abuse and neglect in nursing homes. Research using national data on long-term trends in reporting to long-term care ombudsmen showed a decrease in the reports between 2006 and 2013, with physical abuse by nonresidents most often the reason for the report. Because evidence suggests that resident-to-resident elder mistreatment and verbal and mental abuse and other types of abuse, including emotional abuse, may be more common, the authors of this study raised concern about the findings of their research (Bloemen et al. 2015). Police and emergency responders also are in a position to identify elder abuse and neglect, which should be prioritized by public safety agencies (Kurkurina et al. 2018). Unlike many health and social services personnel, police, firefighters, and emergency medical services can gain access to the homes of older adults in the community and are able to see situations where abuse occurs in context. While many efforts have been made to improve recognition of and reporting of the abuse of older adults in health care settings, the efforts to improve recognition and screening must continue. However, service systems can take action only if they have the capacity to provide a response that will reduce risk and enhance safety while at the same time recognizing the self-determination of the older adults to the maximum extent possible. Adult Protective Services, which receives and investigates reports of elder abuse and neglect, and the aging services system, which recognizes the needs created by the aging process and develops responses, provide services to overlapping populations and focus primarily on older adults living in the community; however, they have not always worked together (Yonashiro-Cho et al. 2017). The service systems are both designed to serve all older adults and are not need-based. The next

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sections of this chapter provide descriptions of these service systems; however, it is important to look at local variations in how services were established and what they emphasize.

Adult Protective Services Adult Protective Services (APS) serves older adults and adults with disabilities who need care, protection, supervision, and assistance with accessing community services and supports because they are at risk of being abused, neglected, or exploited. The majority of APS cases involve self-neglect. In all states, APS responds to and investigates reports of abuse, neglect, and exploitation, and there is great variation between states in terms of eligibility criteria and definitions of elder abuse used (Bobitt et al. 2018). The various APS systems “differ in the populations served, settings in which services are available, timeframes for responses, types of services provided, staffing and training, and relationships with other service providers and the justice system, among other differences” (Bobitt et al. 2018, p. 94). States also differ on whether APS services are centralized, decentralized, a hybrid, or contracted out to private agencies (Mukherjee 2011). APS has an important role in the recent history of response to elder abuse in the United States. In 1962, the Public Welfare Amendments to the Social Security Act authorized states to establish protective services, using legal authority if necessary, for adults who were incapable of managing their own affairs or who were abused, neglected, or exploited. APS continues to receive funds through Title XX of the Social Security Act, passed in 1974, which allocated sums on the basis of each state’s population to use for social services, including protective services to adults. However, there has been no dedicated funding for APS at the national level. When elder abuse was given national visibility in the 1970s due to landmark studies and high profile hearings on Capitol Hill, and interest in “doing something” about elder abuse was high, APS was a service system in place specifically set up to work with older and disabled adults that became closely identified with addressing elder abuse (Otto 2000). Since the passage of the Elder Justice Act in 2010, the federal government, through the Administration for Community Living (ACL), has made efforts to improve APS practices and responses. As mentioned previously, in most states, professionals and others who come into regular contact with older adults are mandated reporters. In a few states, the law states that anyone with a reasonable suspicion is required to report. At times, the extent to which different professional groups fulfill their legal obligations to report (e.g., doctors and other medical personnel and domestic violence advocates) varies due to concerns about what will happen once a report is made. For example, the “feedback loop” to mandatory reporters is not always closed when they do not hear what happened after the report. In turn, they develop mistrust in the system (Jackson 2017). In many states, APS will not help older adults who are abused but do not meet definitions of “care dependent” or “vulnerable.” Most APS programs use

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intervention models such as case management, crisis intervention, and guardianships and other involuntary services, including removal to a hospital or skilled nursing facility. APS workers are guided by core values that include: (1) adults have a right to safety; (2) adults retain their civil and constitutional rights unless those rights have been restricted by court action; (3) adults have the right to make decisions that fall outside social norms unless those decisions harm others; (4) adults are presumed to have the capacity to make decisions unless a court has deemed otherwise; and (5) adults can refuse services (Brandl et al. 2006). This underlying orientation of self-determination means that adults with capacity can refuse interventions offered by APS, a feature of APS that proves frustrating for community referrers who hope that APS can provide immediate action to protect older adults. The APS investigation does not determine if a crime has been committed; however, APS will make referrals to and work with law enforcement when needed. The investigation determines whether the older person is need of protective services; that is, whether the alleged mistreatment (physical abuse, exploitation, neglect) is substantiated and if it is, to provide services if the older adult agrees (Jackson 2017). Older adults, their families, and professionals in other fields who are called upon to refer suspected elder abuse and neglect to APS do not always understand it, and the services are not without controversy. The investigation, which is unique to APS, can put some victims of older adult abuse at risk, depending upon the manner in which the investigation is conducted. For example, APS investigators will conduct unannounced home visits and conduct interviews with collaterals that may end up raising suspicion and leave older adults more at risk (Jackson 2017). In addition, there is little to no research to examine the effectiveness of APS interventions (Ernst et al. 2014). In an effort to improve and standardize services, the ACL led the development of the Adult Protective Services Voluntary Consensus Guidelines, which provide guidance to state APS agencies to identify effective practices that would be expected to lead to effective APS services nationwide. These guidelines were prepared with the input of experts in the field and implemented after various stakeholders including the public, the disabilities network, law enforcement and legal systems, the longterm care network, groups representing tribal interests and the minority aging community, and domestic violence, sexual assault, and victims’ services networks provided comments and feedback (Administration for Community Living 2016). The guidelines offer direction to APS agencies in the areas of program administration; time frames for response, completion of investigations, and case closure; receiving reports; conducting investigations; service planning for both voluntary and involuntary interventions; training of APS workers; and evaluation and program performance. For example, the guidelines recommend that APS agencies develop a conceptual framework for practice and an ethical code that workers can use when challenged by the complicated ethical situations that are the hallmark of APS practice. These ethical foundations include that adults who are reported to APS should be offered the least restrictive alternatives, person-centered services, a trauma-informed approach, and supported decision-making (Administration for Community Living 2016).

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An analysis of the comments made on the draft of the guidelines highlighted the need for clear definitions and processes used in APS, and the extent to which the guidelines will influence APS practices nationwide remains to be determined (Bobitt et al. 2018). The attention to APS has resulted in improved services. For example, a number of new assessment and case management tools have been developed, such as structured decision making, the Elder Abuse Decision Support System (EADSS), and the APS Tool for Risks, Interventions, and Outcomes (TRIO) system (Moore and Browne 2017). The ACL has initiated a number of programs to improve APS practice, including the Adult Protective Services Technical Assistance Resource Center. Since 2015, they have made grants available through State Grants to Enhance Adult Protective Services and the Elder Justice Innovation Grants program to build knowledge and improving processes related to APS and other efforts to respond to elder abuse, with many of these grants involving partnerships between APS agencies and universityaffiliated social work researchers (Colello 2017). The ACL also initiated the development of National Adult Maltreatment Reporting System (NAMRS), a comprehensive national reporting system that allows for the collection of reliable data on exploitation and abuse of older adults and persons with disabilities that will facilitate the examination of APS processes and outcomes on a national level. NAMRS will facilitate research that will assist in the development of evidence-based interventions and best practices (Bobitt et al. 2018). In 2015 and 2016, funding from ACL demonstration grants focused on assessment tools and data collection systems consistent with NAMRS. Grants awarded in 2018 focus on the development of evidence-based or evidence-informed intervention methods that are implemented consistently. While some focus on ability to collect and report data consistent with NAMRS, others seek to improve methods of intervention through the use of improved screening methods, motivational interviewing, goal attainment scaling, supported decision-making, restorative justice, and use of teams (Administration for Community Living 2018). In some states, APS is housed within the state’s aging network, another important aspect of the social service system response to older adult abuse, while in others APS resides with the Department of Social Services. No matter where the program is housed, Adult Protective Services often work with or refer older adults to programs offered by the aging network.

The Aging Network A variety of programs and agencies created to help older adults navigate the aging process are collectively known as “the aging network,” which is “an approach that seeks to balance national standards, a consistent structure, and core services with opportunities for local innovation based on the needs of individual communities” (Yonashiro-Cho et al. 2017, p. 298). It includes some programs that address older adult abuse due to recognition of needs created by the aging process. The Older Americans Act (OAA), first passed in 1965, provides the structure (mostly state units

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on aging) and identifies the types of services that will be provided including nutrition, personal care, disease prevention and health promotion, legal services, transportation, family caregiver support, and personal care. Title VII of OAA, added in 1984, specifically addresses elder abuse, but other provisions of the OAA “offer more general services that nonetheless can be employed to support victims and help reduce the risk of abuse” (Yonashiro-Cho et al. 2017, p. 299). For example, caregiver support programs can serve as prevention. Title VII established the long-term care ombudsman program and allocates money for prevention of elder abuse, and also set up National Center on Elder Abuse, now housed at the University of Southern California. The most recent reauthorization included several new program requirements that explicitly address elder abuse, including, for example, developing community partnerships addressing elder justice and implementing health screenings that also include screening for abuse and neglect. The involvement of the Federal Government in elder abuse over the past 30 years, while far outpaced by the interest in and attention to child abuse and to violence against women, has increased. The programs and services that comprise “the aging network” and Adult Protective Services provide a wide-ranging and varied nationwide network of government-funded providers serving older adults – and responding to the abuse of older adults – in their local communities.

Domestic Violence and Victims’ Services Domestic violence and victims’ services programs also respond to the abuse of older adults, particularly older women. These services are not always “age-friendly” in the ways in which they provide services to older adults. “Victims’ services” take action for and on behalf of victims of crime. Federal funding from the Victims of Crime Act of 1984 (VOCA), which was the result of activism highlighting that the needs of the victims of crime were not met by law enforcement and in the legal arena, gave the states funding to address the needs of victims of any type of crime. Most programs funded by VOCA serve victims of sexual assault and domestic abuse. Crime must have occurred for eligibility for services (for summary, see Jackson 2017). Many victims’ services organizations are not skilled in meeting the needs of older adult victims. The American Bar Association Commission on Law and Aging recommended during the 1990s that advocates for victims of crime should be trained about the dynamics of elder abuse and about the APS system and other aging network services available to assist older abused persons and that there should be an elder abuse specialist at every victim/witness program (Stiegel 2017); however, this has not happened. Domestic violence is a pattern of abusive behavior that one person uses to control another (Cramer and Brady 2013). Historically, domestic violence services were developed to meet the needs of women who were victims of violence at the hands of their husbands or partners. Sexual assault services were intended for victims of rape or other forms of sexual assault. Services emerged from grassroots, feminist

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organizations rooted in communities that recognized the need meet the needs of the predominantly female victims of such crimes, who were not served well in the law enforcement arena. Services to address domestic violence specifically received recognition and resources with the passage of the Violence Against Women Act (VAWA) of 1994, which has since been reauthorized three times. VAWA fostered community-coordinated responses to domestic violence that attempted to bring together the systems – criminal justice, social services, and private non-profit organizations responding to DV and sexual assault. As a federal law VAWA enabled interstate enforcement of protection orders and federal prosecution of interstate DV and sexual assault crimes. It brought new protections for immigrants experiencing DV and protections for underserved populations such as Native Americans (National Domestic Violence Hotline 2019). While funds specifically designated to serve older women (defined as women over the age of 50) were made available in the VAWA reauthorization in 2000, they are limited. Older adults who have been abused, particularly older women, use domestic violence and victims’ services. Therefore, these services must recognize the unique needs of older adults by making the services physically accessible, welcoming (e.g., through outreach materials that depict older women), through development of expertise of staff and volunteers with respect to older adults, and through agency policies on service eligibility. For example, agencies need to make sure that their definitions of “domestic violence” include more than intimate partner violence, because much of the abuse experienced by older adults is at the hands of their adult children and grandchildren (Brandl 2016). With respect to the abuse of older adults, victims’ services have similar values but they are distinguishable from APS in a number of ways (Jackson 2017). The two service systems have different philosophies, definitions, and practices concerning the abuse of older adults. The service settings tend to have very different organizational culture. APS is usually part of a state or county social services system with workers who are government employees. Services provided in the victim services network traditionally have been geared towards younger victims of domestic violence and sexual assault and they are not always equipped with the knowledge needed to address the unique needs of older adults, particularly women, who were victims of domestic abuse. In fact, older women have been described as “invisible” as victims and survivors of intimate partner abuse who are not particularly served by either the domestic violence or the adult protective services system (Crockett et al. 2015). In many states, APS requires vulnerability or impairment of some sort to be eligible for services; however, in some, “advanced age” (usually age 65) is one of the vulnerabilities listed in some state statutes. Ideally, APS and domestic violence organizations would work together to respond to the abuse of older adults at hands of spouses and other family members. However, the issue of mandated reporting creates conflicts for DV workers. Even though “APS and DV programs actually have some very similar values about community life (for example, freedom from harm, right to safety and quality of life, respect for dignity of persons),” they “have very different ways in which those values are manifested in the work of their agencies. Furthermore, these organizations

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do not view these differing conceptions of the same values as ‘equally plausible’” (Cramer and Brady 2013, p. 462). Thus, the challenge is to develop ways in which the organizations can come to mutual understanding of the service approach and philosophy of the other, and to work together on behalf of older adults who are abused (Cramer and Brady 2013). Both APS and victims’ services organizations have embraced the principle of self-determination, even though there are limits to which clients can exercise it (Jackson 2017). Both fields have to address the issue of the continued presence of the perpetrator of abuse in the life of the older adults. Jackson (2017) recommends that both APS and domestic violence and other victims’ services continue to work with victims who choose to live with their offenders. A victims’ services program that specifically targets older adults is the New York City Department for the Aging Elder Crime Victims Resource Center (ECVRC). The services provided by ECVRC include case management, seeking orders of protection, developing safety plans, and guidance throughout the legal process. Efforts to improve these services include the introduction of routine screening for depression and anxiety into the intake process, and the provision of services designed to help the older adults reduce depression and anxiety (Sirey et al. 2015). The LEAP (Law and Social Work Elder Abuse Program), which provides both legal assistance and social services to older adults who are abused, is another example of a program that combines legal expertise with knowledge about social services needs to older adults who do not meet state-defined eligibility requirements for APS (Rizzo et al. 2015). Organizations such as ECVRC and LEAP provide assistance with and access to the legal system.

Criminal Justice and Legal System Responses Federal direction for the response to older adult abuse comes from the U.S. Department of Justice, which has made considerable efforts to shore up the justice system’s response. The Elder Justice Initiative (EJI) supports and coordinates the Department’s response in four ways. First, the EJI provides training and resources to professionals including law enforcement, prosecutors, and judges to improve efficiency and effectiveness of the responses. Second, the EJI promotes justice through investigation and targeting of financial scams and addressing substandard care in long-term care settings. Third, the EJI supports research into elder abuse and financial exploitation and fourth, the EJI offers resources, information, and referrals to families in need of assistance (U.S. Department of Justice n.d.). The projects funded under the EJI have added to our understanding of how to improve how the legal system addresses the abuse of older adults. Older adults who are involved in the legal system receive assistance through domestic violence and victims’ services programs described above. In addition, civil, criminal, and judicial systems are in place to respond to myriad aspects of elder abuse. Stiegel (2017) outlines a number of recommendations to improve these systems. Much improvement depends on the provision of additional training and

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resources; however, barriers to acquiring additional training, resources, and knowledge exist. For example, while law schools have increased the number of courses in elder law over the past 40 years, they are often taught by adjunct faculty, who do not produce much scholarship on the topic. Tenure-track faculty are less likely to produce scholarship on elder law for widely read law reviews or to integrate issues of law and aging into their courses (Doron 2020). Only 30 of over 200 law schools in the United States have elder law clinics, which provide specialized training in working with older adults, including elder abuse (Bensco et al. 2017). More exposure to elder law issues and scholarship in non-elder law journals would enhance knowledge and awareness across the legal profession. Many barriers hamper access to the civil justice system, which, for example, is necessary in helping gain protective orders. Nonlegal professionals do not always understand how civil legal system could be helpful to victims of elder abuse, and civil lawyers do not always understand elder abuse. Lawyers must be versed in many different legal and other topics to address elder abuse. Examples of topics include banking and securities law for financial exploitation, domestic violence, guardianship, decision-making capacity, benefits law, and trusts and estates (Stiegel 2017). In particular, those who work with abused older adults must understand the uses and limitations of guardianship as a means of protecting older adults from abuse. Guardianship reduces a person to the legal status of a minor and permanently takes away his or her rights to make decisions related to finances, health care, and living arrangements. Thus, the decision to seek guardianship raises legitimate concerns and highlights the ethical dilemma of self-determination versus protection of older adults. Concerns about guardianship include legal standards for incompetence and incapacity, concerns that family members rather than the person needing guardianship are protected, and insufficient court oversight of the system. Advocates for older adults see guardianship as a last resort process and that other, less restrictive options should be exhausted beforehand (Wood 2012). In recent years, lawyers and other advocates have made many efforts to improve the response of the criminal legal system to elder abuse, including increasing prosecution of elder mistreatment perpetrators and financial exploitation of older people. The difficulties in bringing these cases to justice include the reluctance of victims to testify against family members and concerns about the ability of victims to be reliable witnesses. The criminal justice system needs the assistance of different systems (e.g., health, social and aging-related services including APS, and financial services) and knowledge contributed by different types of professionals in prosecuting cases involving elder abuse in order to achieve justice for victims (Heisler 2012).

A Multidisciplinary Response Over the past 20 years, the development of multidisciplinary teams (MDTs) and other collaborative efforts has assisted in bringing more elder abuse cases to justice, though the need to create teams and study the effects of multidisciplinary teams to elder abuse remains. The complexity of older adult abuse and the need for multiple

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types of expertise has sparked development of different models of multidisciplinary responses to elder abuse. These innovations and developments in legal, medical, and social service settings strive to improve responses so that the different needs of the older adult (health, legal, psychosocial) can be met (Brandl et al. 2006). MDTs vary in their purpose, format, and professional “home,” but they all share the goal of improving services across many systems (Pillemer et al. 2016). Multidisciplinary teams that include APS staff can collaborate for a more effective response to elder mistreatment. The Elder Justice Act called for the development and support of Elder Abuse Forensic Centers, which assist Adult Protective Services in their response to complex cases through providing specialized expertise in, for example, capacity assessment or geriatric mental health. EAFC teams examine, document, and work toward prosecution of cases of elder abuse, many of which are involved with APS. For example, these teams can make home visits with APS workers to reduce the need for multiple referrals and interviews. These centers have increased prosecution in cases of financial exploitation (Navarro et al. 2013). The APS Voluntary Consensus Guidelines described above note support for the further development of teams (Administration for Community Living 2016). Different types of team responses can happen at different points in elder abuse intervention. Professionals and service systems need to explore and develop different ways to work together. There will be few cross referrals between APS and domestic violence organizations if workers are unaware of dynamics of family violence and DV services that are not equipped to serve older victims (Kilbane and Spira 2010). Staff from organizations that provide domestic violence and sexual assault response services can work collaboratively with APS and law enforcement, train other community providers, and lead coordinated response teams (Brandl 2016). Within the health system, advances have been made in setting up systems for multidisciplinary response in primary care and, as mentioned above, in emergency rooms (Rosen et al. 2018). An example of a promising innovation is an approach piloted by APS in Texas that trained primary care physicians in a number of clinics to use a version of the Elder Abuse Suspicion Index to screen and triage older adults. Multidisciplinary teams can also strengthen the response of the legal system. For example, a law enforcement officer and victim advocate working together can result in a dual focus on collecting evidence and meeting the needs of the victim of abuse. Teams in prosecutors’ offices can focus on identification of cases, building evidence, and helping victims. Fatality review teams can ensure that deaths resulting from abuse are properly documented and can highlight the need for better recognition and understanding of injuries and conditions that are the result of abuse or neglect (Heisler 2012).

Key Points • The aging, health care, domestic violence, victims’ services, and criminal justice systems, which vary in philosophy and approach, play an important role in the response to older adult and elder abuse and must work to improve their knowledge of the unique needs of older adults.

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• Recognizing and reporting elder abuse involves training of professionals who work with older adults and the development of valid and reliable screening tools. • Adult protective services, which varies by state law and local practice, receives reports from and works with other systems in the investigation and amelioration of elder abuse and is guided by core values including the victim’s right to selfdetermination. • The development of different types multidisciplinary teams has enhanced the systems response to older adult abuse.

Summary and Conclusion All concerned about how we respond to elder abuse must develop strategies to communicate so that the general public can understand it as an issue that requires public concern and that solutions must involve the empowerment of older adults as agents who can make determinations about their own needs and the strengthening and improvement of institutions that are set up to respond to the elder abuse (Volmert and Lindland 2016). As the population of older adults continues to grow, we must continue to work to improve the response of all of the systems to all forms of abuse. Increased funding for systems will help ensure that the response is timely and adequate. Further research to develop a better evidence base for current screening and intervention programs as well as for new and innovative programs will assist in determining the best ways to address this complex problem.

Cross-References ▶ A Feminist Perspective on the Criminal Justice System Response to Domestic Violence ▶ Future Directions in System Responses to Interpersonal Violence and Abuse: Community Perspectives ▶ Intimate Partner Violence and Intimate Partner Stalking ▶ Perpetrators of Elder Abuse ▶ Recognizing the Trauma Experienced by Community-Dwelling Older Victims of Financial Abuse Perpetrated by Trusted Others ▶ System Response to Intimate Partner Violence: Coordinated Community Response ▶ The US Mental Health Care System’s Response to Intimate Partner Violence: A Call to Action

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aging Population in Asia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Population Aging, Economic Growth, and Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sociocultural Specifics and Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intergenerational Relationships and Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . East Asia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . South Asia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Middle East: Arabs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gender and Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Women as Victims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Culture-Specific Forms of Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Culture-Specific Response to Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. E. Yan (*) Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hong Kong, Hong Kong e-mail: [email protected] B. Fang Department of Sociology and Anthropology, Sun Yat Sen University, Guangzhou, People’s Republic of China © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_93

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Abstract

Asians represent one of the fastest growing aging populations. Traditionally, intergenerational relationships in Asian countries are governed by the Confucian principle of filial piety, which prescribes to parents the responsibility to care for their young children and to adult children the duty to respect and support their aged parents. Urbanization, globalization, and industrialization, however, have resulted in social and demographic changes that challenged this model of intergeneration exchange. Available evidence shows that the younger generations adhere less to the traditional Confucian principles of filial piety. Older Asians are no longer guaranteed care and respect in their families. In fact, many are subjected to abuse and neglect. This chapter examines the changing sociodemographics and cultural values in Asia and their implications for elder abuse. The authors highlight four major areas: (1) population aging and socioeconomic changes, (2) changing intergenerational relationships, (3) gender issues, and (4) cultural and social responses to elder abuse. Keywords

Elder abuse · Asia · Familism · Filial piety · Collectivism · Patrilineality

Introduction Elder abuse is a prevalent health and social justice threat across socioeconomic and ethnic groups. Compared to the rest of the world, elder abuse is becoming an especially pressing issue in Asia as many Asian countries are aging at an unprecedented pace. A substantial amount of research has accumulated on elder abuse in Asian populations. The present chapter aims to provide an overview of the social and cultural context, as well as the current state of knowledge of elder abuse in Asian countries.

Aging Population in Asia As a result of longer life expectancy and reduced birth rates, the population of Asian countries has been aging at a rapid, and alarming, rate (Horioka et al. 2018). While the speed in which such transformation takes place varies among different countries, as a whole, the region is undergoing an unprecedented demographic change. As of the end of 2016, approximately 12.4% of the population in Asia was 60 years of age or older. This figure is expected to increase to 25% (or 1.30 billion) by the middle of this century. Such change will be particularly drastic in East and North Asia, where it is estimated that one third of the total population will be 60 or older by 2050.

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Population Aging, Economic Growth, and Elder Abuse One epidemiological survey has reported that population aging is happening more rapidly in less developed regions than in developed regions (United Nations et al. 2013). It is estimated that by 2050 the older population of less developed regions will make up 80% of the world’s overall older population (United Nations et al. 2013). This finding is particularly relevant to Asia, where some of the world’s poorest countries are located (World Bank 2018). Population aging can have a great impact on the economic growth of a region, as it can lead to lower productivity, reduced savings, higher government expenditure, and a greater burden on social welfare systems (Sharpe 2011). It will also lead to a higher age dependency ratio, i.e., a diminishing workforce is tasked with taking care of the growing older population, resulting in tremendous pressure on individuals, families, and society as a whole (Hock and Weil 2012). Rapid population aging and its effects on economic development have brought into question the viability of the older population relying solely on their families for support (Chen and Silverstein 2000). Although adult children have continued to be the primary source of care and support for their parents, the nature of intergenerational relationships and family dynamics are undergoing dramatic transformations in Asia (Choi et al. 2008; Kagitcibasi et al. 2010; Silverstein et al. 2006), as the growing longevity of older adults and reduced average family size lead to extra workload and stress on the part of family caregivers (Watt et al. 2014), one of the most serious consequences of which is elder abuse (Gainey and Payne 2006).

Sociocultural Specifics and Elder Abuse Cultural values and social norms often have profound influence on key aspects of intergenerational relationships and family dynamics, such as how the aging process is perceived, the manifestation of intergenerational interactions, and the familial expectations of both the young and the older (Choi et al. 2008; Kagitcibasi et al. 2010). In many Asian societies, such as China, Japan, South Korea, Taiwan, Cambodia, and Thailand (Zhang et al. 2005; Onishi and Bliss 2006), intergenerational relationships are governed by Confucian philosophy, which puts the emphasis on the moral principle of filial piety that in turn prescribes to parents the responsibility to care for their young children and to adult children the duty to respect their parents and support and care for them when they reach old age (Ng et al. 2002). However, times are changing. Recent research has shown that while older parents still hold filial expectations toward their adult children, the younger generation today interprets the concept of filial piety quite differently from their parents (Yan et al. 2015). Even though many young adults continue to consider it a virtue to conform to traditional cultural expectations and reciprocate care to their parents, many also contend that the performance of filial obligations should depend on actual circumstances such as the availability of resources (Tsai et al. 2008).

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It should also be noted that gender plays a significant role in filial expectations, which are closely connected with the traditional concept of patrilineality. Sons and daughters-in-law are expected to assume a primary role in providing care to the older parents, maintaining family unity, preserving family integrity, and performing rituals of ancestor worship (Ho 1996). Filial piety is also closely connected with the value of collective familism, which emphasizes the prioritization of the needs and welfare of one’s family over the individual’s own interests and desires (Li 2014). Familism, which has been internalized in intergenerational relationships in Asian families through the ages, stresses the importance of fulfilling familial obligations, maintaining kin relations, respecting the seniors in the family, and protecting the family reputation (Yang 2006). Family members are expected to provide mutual support to one another, maintain family relations through patience and endurance, and protect family members from external threats (Leung 2017). These institutionalized norms have created a solid moral basis for intergenerational co-residence, which facilitates intergenerational support and the sharing of family resources (Mehta 2007). Co-residence also allows senior members of the family to benefit more readily from the support provided by their adult children to cope with health issues and financial needs (Li and Huang 2017). However, in contemporary Asian societies, such living arrangement can often lead to intergenerational conflict, which is further aggravated by differences in the values and views on everyday issues held by different generations (Takagi and Silverstein 2006). Moreover, economic growth and increased social mobility brought along by urbanization, globalization, and industrialization in many Asian countries have not only altered the interpretation of filial piety and collective familism by younger adults (Yeh et al. 2013), but they have also lead to social and demographic changes that weaken intergenerational support (Chen and Silverstein 2000). For example, although multigenerational co-residence remains prevalent in Asia (Yasuda et al. 2011), it is becoming more and more common for younger adults to move away from their hometown to pursue employment opportunities, leading to increased geographic separation between generations and making it difficult, if not impossible, for the elderly to reside with their adult children in a stable family environment (Silverstein et al. 2006). Women, who have traditionally taken up the role of primary caretakers, have in recent decades become a vital part of the workforce, which means more and more of them simply lack the time and capacity to take care of older family members (Tsutsui et al. 2013). The situation is further complicated by the general underdevelopment of public social support networks for the elderly, as is the case of many countries in the region, which may have been caused by the prevailing Confucian belief that elderly care is primarily the responsibility of the family (Fan 2007). In the face of socioeconomic and familial burden deriving from changing values and social demographics, governments in many Asian countries have increased awareness of various issues related to the elderly, such as chronic illness, longterm care arrangement, and the growing family caregiving demands that can potentially lead to an increased risk or severity of elder abuse or neglect (Shankardass 2013). A recent systematic review of studies on the subject in Asia and Europe

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has reported that the prevalence of elder abuse in Asia ranges from 2.2% to 62% (Yan et al. 2015), which is significantly higher than the prevalence of 3–25% in Europe (World Health Organization 2011), after taking into consideration differences in methodology.

Intergenerational Relationships and Elder Abuse The extent and patterns of elder abuse can vary greatly depending on the specific cultural context where it takes place. Although intergenerational relationships in most Asian societies are deeply intertwined with traditional cultural values such as filial piety and collective familism, there are other culture-specific factors at play that give rise to variations in the form and characteristics of abuse.

East Asia East Asian countries such as China (People’s Republic of China, Hong Kong, Macau, and Taiwan), South Korea, and Japan are at the stage of social and economic development where both traditional and contemporary interpretations of filial piety and collective familism coexist (Yeh et al. 2013; Hyun 2001; Tsutsui et al. 2013). Although family relationships in these countries remain interdependent and collectivist, an emerging emphasis on individualism and independence has increasing influence over younger generations (Jang 2009), who interpret traditional values differently. While many older adults in these countries continue to expect their adult children to provide emotional and financial support and hands-on care unconditionally (Cheng and Chan 2006; Du 2013; Hyun 2001; Tsutsui et al. 2013), the younger generation tends to interpret filial piety as providing care and support to their parents depending on their parents’ actual needs and only if such provision is feasible. For instance, in Chinese societies today, younger adults tend to perform their filial duties through various forms of repayment, taking into consideration the level of mutual affection and on the basis of equality between parent and child, as opposed to absolute obedience and unconditional care (Yeh et al. 2013). More and more younger adults in Chinese societies such as Hong Kong and Taiwan fulfill their filial obligation by paying their parents’ nursing home or home-care service expenses rather than personally taking care of them. While such arrangements enable the adult children to take care of their own needs without neglecting their parents’, these actions are often considered unfilial or perceived as abandonment by older Chinese (Zhang 2004; Yan et al. 2015). In order to prevent or at least delay what they perceive to be abandonment, many older Chinese in Taiwan have in recent years started to engage in a new type of “quasi-co-residence” living arrangement known as “rotation” (Lin and Yi 2013), where adult siblings take turns to provide accommodation and meals to their parents (Li and Huang 2017). Some parents, however, consider such arrangement as improper treatment as it prevents them from living

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with a particular child and they need to constantly move between different homes (Lin and Yi 2013; Yasuda et al. 2011). The transformation of intergenerational relationships has also brought about changes in the use of language between generations. It has been observed in China, Japan, and South Korea that younger adults today tend to use less respectful language when talking to their parents (Yue and Ng 1999; Kim 2002; Sasaki et al. 2007), which is often perceived as verbal abuse by the parents (Tam and Neysmith 2006; Kim 2002). Cultural values and social norms often play a key role in the development of the prevalent living arrangement practiced in a society (Silverstein et al. 2006). In East Asian countries such as China, Japan, and South Korea, where Confucian values of familism and collectivism prevail, intergenerational co-residence is a symbol of family prosperity and harmony (Lin and Yi 2013) as it implies the adult children have the resource to fulfill their filial obligation by taking care of their parents and providing financial support and companionship (Ting and Chiu 2002). Such arrangement is also in line with the traditional concepts of altruism and collectivism, which emphasize collaboration between family members to maximize available resource and facilitate equitable distribution for the benefit of all family members. It is a commonly held belief that these objectives are best realized by intergenerational co-residence (Zhang et al. 2014; Takagi and Silverstein 2006; Yasuda et al. 2011). Meanwhile, other practical considerations, such as rising housing prices, growing cost of living, and urban housing shortage in East Asian countries, have also contributed to the prevalence of co-residence (Kim and Park 2016; Mao and Chi 2011). According to a recent epidemiological study, the prevalence of intergenerational co-residence in urban China, Japan, and South Korea ranges from 8.6% to 29.8% (Yasuda et al. 2011). While parent-children co-residence is thought to facilitate intergenerational support, the adult children’s ability to physically care for co-residing parents is often compromised by growing demands from the workplace which have become a staple of the modern-day economy in these regions (Chong et al. 2014). Consequently, domestic helpers are often hired to take over the role of primary caregiver in China, Japan, and South Korea (Tanaka 2017; Kwon and Chun 2011; Chong et al. 2014). As the older adults of these countries often consider it their adult children’s moral obligation to care for them personally, the employment of domestic helpers is commonly regarded by them as abandonment or at the very least neglect (Ministry of Health, Labour and Welfare of Japan 2004; Lee and Lightfoot 2014). Another problem associated with intergenerational co-residence is the enhanced risk of intergenerational conflict, which is often a result of differences between generations with regard to expectations, lifestyles, habits, and other everyday matters (Arai 2006; Takenoshita 2007). Adult children who fail to adopt effective coping strategies may resort to maladaptive and aggressive behaviors, the worst-case scenario being elder abuse (VandeWeerd et al. 2013). For example, in multigenerational co-residing households in Japan, as a result of the strong mother-son attachment that has long become an integral part of

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Japanese family values, it is common for mothers-in-law to interfere with their son’s marital affairs and expect their daughter-in-law to obey their son completely (Takagi and Silverstein 2011). A son’s indifference to such interference may lead to resentment on the part of the wife, which can easily evolve into conflict-prone (Soeda and Araki 1999) or abusive (Arai 2006) in-law relationships. As a matter of fact, in many cases, contrary to the general belief that co-residence can promote intergenerational exchange and family harmony, such living arrangement may instead put older adults at an increased risk of mistreatment, the prevalence of which is often difficult to assess given the private nature of such households (Yan et al. 2015).

South Asia South Asian countries, such as India, Bangladesh, Thailand, Vietnam, and Nepal, share similar cultural norms. It is essential, in order to better understand the subject of elder abuse in South Asia, to take into account the unique traditional and historical family values that are prevalent in the region. Similar to the case of most East Asian societies, the concept of family and intergenerational relationships are undergoing transformation in many South Asian countries such as India and Bangladesh, where the younger generation has developed a different understanding of traditional moral norms (Jamuna 2003). In the past, caring for senior family members was considered an absolute obligation that has to be fulfilled regardless of circumstance, and failure by a family member to provide such care was often portrayed as morally detestable (Dey 2016). However, in light of recent social changes, this obligation to provide support has evolved from obligatory and unconditional to utilitarian and conditional (Jamuna 2003; Kabir 1996). For example, it has been noted that adult children are more likely to provide more and better care for their aged parents if the parents assist in taking care of the grandchildren, which often results in healthier and more rewarding intergenerational relationships (Burholt and Wenger 2003; Gangopadhyay 2017). In contrast, nonreciprocal relationships have been associated with a higher likelihood of caregiving stress, frustration, and intergenerational tension (Koenig et al. 2003), which can potentially lead to a higher risk of elder mistreatment (Munsur et al. 2010). Under the traditional norms in South Asian countries such as Thailand, India, and Bangladesh, an ideal family is usually headed by the grandfather who is the patriarch and the grandmother who acts as his deputy in managing family issues and making major family decisions (Kalavar et al. 2015; Munsur et al. 2010; Dhar 2012). However, the younger generation has shifted away from strict conformity with tradition and brought about changes to the patriarchal system in these countries (Kalavar et al. 2015). This can at least be partly attributed to the growing economic advantage adult children have acquired over their aged parents, most of whom have been lifelong agricultural workers, which advantage has led to a stronger desire for individualism (Kalavar et al. 2015; Munsur et al. 2010)

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and undermined traditional parental authority, which in turn often render intergenerational relationships (Tareque et al. 2015) prone to conflict. Recent research has also reported an increase in the number of couples where both partners are engaged in full-time employment, which deprives them of the ability to take care of older parents. In many cases, the unavailability of family support coupled with the need to devise alternative arrangements can be a source of great tension (Bhattarai 2014). Such tension is particularly common in societies where sons and daughters-in-law traditionally assume the role of caregiver and become what is generally accepted as “old age security,” as is the case in India, Thailand, the Philippines, Nepal, and Bangladesh (Kalavar and Duvvuru 2008; Bhattarai 2014; Kabir 1996; Ofstedal et al. 1999). Improvements in medical technology and sanitary condition in these regions have brought about higher life expectancies, but that also means more and more older adults are living with chronic conditions and various types of cognitive and physical impairment (Mallik 2001; Chokkanathan and Natarajan 2018; Farid 2017; Bhattarai 2014), which may make the task of caregiving increasingly challenging and strenuous for their adult children. As more and more women – traditionally the primary family caregivers – join the workforce as a result of urbanization and increased social mobility (Kalavar et al. 2013; Bhattarai 2014; Farid 2017), more and more older adults find themselves in the situation where “old age security” is no longer secure (Chokkanathan and Natarajan 2018). Abuse can be very culture-specific. For example, social abuse, which refers to the exclusion of older adults from major family activities such as decisionmaking, has been identified as a unique form of abuse commonly found in Indian societies (Bambavale 2004). Other culture-specific types of abuse caused by the erosion of family values and parental authority include demeaning remarks, name-calling, and financial exploitation (Bambawale 1996; Kalavar et al. 2013; Jamaluddin et al. 2015). Intergenerational co-residence is highly prevalent in India, the Philippines, Thailand (Ofstedal et al. 1999), and Vietnam (Knodel et al. 2000). This is partly attributable to the general underdevelopment of social welfare systems in these regions, which limits the ability of older adults to support themselves (Mandemakers and Dykstra 2008), and also the social stigma often attached to older adults living alone, which is often perceived as evidence of failure on the part of adult children to fulfill their filial obligation, which in turn is often regarded as an indication of poor parenting and disharmonious family relationships (Kalavar et al. 2015). The prevalence of intergenerational co-residence inevitably leads to intergenerational tension as a result of difference in opinion over matters such as power distribution, traditional values, and lifestyles (Knodel et al. 2000; Johar et al. 2015), and such tension is often a strong predictor of elder abuse (Lee 2008). That being said, many older adults in these countries still prefer to live with their adult children rather than in care facilities, primarily because of the social stigma attached to them (Johar et al. 2015). An older adult living alone or at a nursing home is often considered a product of neglect, abandonment, or violation of tradition (Liebig 2005).

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The Middle East: Arabs Arabs constitute the majority ethnic group in the Middle East. Over the centuries, Islam has become the prevailing religion in the region and today plays a key role in various aspects of familial and social life (Fazeli 2008). Older Arabs are commonly regarded as the source of wisdom, knowledge, and experience (Giles et al. 2012). They are treated with respect and enjoy certain privileges in both family and society at large (Tajvar et al. 2008). According to the Quran, Muslims should respect the elderly and treat them as valuable members of society, while similar sentiments have also found expression in Persian literature and poetry (Giles et al. 2012). Over the past few decades, Middle Eastern countries such as Iran and Iraq have experienced significant cultural, political, economic, and societal changes that have greatly affected the socialization of different generations (Ghazi-Tabatabaei and Karimi 2011), with some important examples being the Iranian Revolution, the Iraq-Iran War, the establishment of an Islamic-democratic government in Iran, and the formation of an Islamic-democratic-federal parliamentary government in Iraq (Yazdani and Ghaderi 2011). The current generation of older adults in Iran and Iraq, who were born and raised before the Iranian Revolution and the Iraq-Iran War, tend to uphold traditional beliefs such as principles rooted in Islamic ideologies, preference for a religious and simple life, and intentional avoidance of secular luxuries (Sohrabzadeh 2010). The increase in literacy rate and the establishment of a more democratic government in recent years have brought about a greater degree of socialization among young adults as well as more consumerist values, as reflected in the social behavior and consumption patterns of the younger generation (Sohrabzadeh 2010). The resulting decline in strict conformity with Islamic and religious values has given rise to new communication patterns between generations (Giles et al. 2012). For instance, in the past younger adults tended to consult senior family members on matters involving major life decisions, but it has become increasingly common for younger adults to make those same decisions on their own, which is sometimes regarded as disrespect or even neglect by older Arabs (Nassiri et al. 2016). The supreme social status prescribed by religion and tradition upon older Arabs manifests in various daily activities and intergenerational interactions. For example, the young are expected to use respectful language when talking to the elderly (Giles et al. 2012; Ghazi-Tabatabaei and Karimi 2011). When older adults enter a room, the young are expected to rise and offer them the best seats. During meals, the elderly are always served before others (Giles et al. 2003). However, influenced by the recent economic and social transformation, many younger Arabs in Iraq and Iran have started to lead a more secular lifestyle and adhere less rigidly to Muslim religious norms (Asso et al. 2014; Irudaya et al. 2005). The weakening of traditional and religious influence on younger adults means that older Arabs can no longer secure respect, prestige, and unconditional support from the family (Oveisi et al. 2014), which often leads to insecurity, loneliness, anxiety, and an increased risk of falling victim to mistreatment (Sheykhi 2010).

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The classic traditional Arabic household structure is characterized by hierarchy and intergenerational solidarity (Tajvar et al. 2008). Family members usually reside under the same roof or in close geographical proximity with each other and have frequent contact in order to maintain emotional connectedness and provide reciprocal support to one another (Rasmi and Daly 2016). A recent research study has shown that intergenerational co-residence remains the prevailing living arrangement in the region, with over 60% of older Arabs residing with their adult children (Burholt and Dobbs 2010). While a shared living environment allows younger adults to more readily fulfill their filial obligations and provide kin-based mutual support as prescribed by traditional social norms (Lowenstein and Katz 2005), growing differences between generations in the interpretation of such norms, coupled with the effect of the aforementioned sociocultural transition, frequently lead to discord in multigenerational households and the weakening of traditional core values such as reciprocity, solidarity, stability, and mutual trust (Lavee and Katz 2003). Conflicts also often arise when different family members within the same household react differently to modern lifestyles and values in terms of acceptance and adjustment (Lowenstein 2007). When conflicts occur, the elderly tend to be the ones more prone to abuse given their physical frailty and inability to defend themselves (Litwin and Zoabi 2003). The resulting erosion of intergenerational solidarity and emotional closeness between co-residing family members may further undermine their morale and ability to cope collaboratively with family stressors (Lowenstein and Katz 2015). It has been observed that family members in such scenarios are more likely to turn their frustration into abusive behaviors against their older relatives when faced with a family crisis or adverse situation where the resulting stress exceeds what the family’s coping resources and capability can handle (Mitrani et al. 2006). Middle East: Israel Jews constitute another important ethnic group in the region. Older Jewish adults are traditionally considered the connection between the past and the present, as well as the primary channel for the transmission of experiences and values (Sharon and Zoabi 1997). As most of the elderly are Holocaust survivors, they are highly revered and enjoy supreme status in both family and society (Katz and Lowenstein 2012), although it has been argued that their wisdom and experience are so often celebrated to such an unrealistic degree it becomes problematic (Litwin and Zoabi 2010). Modernization and industrialization brought about by globalization in the past few decades have greatly impacted the lives of older Jews. For example, with the emergence of modern courts and schools, older Jews are no longer in the position to perform their historical social roles as mediators, arbitrators, and educators (Sharon and Zoabi 1997). With their adult children joining the workforce and becoming the main source of family income, older adults have gradually lost their financial advantage in the family (Lowenstein 2007). The reduction in family size with fewer children living in the same household with their grandparents has further limited and challenged the latter’s influence and authority within the family as they are often no longer needed for child-rearing and household management (Geffen 2014) (Even-Zohar and Sharlin 2009). The patriarch of the family, who used to enjoy

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absolute authority, financial advantage, and decision-making power in the family, has become increasingly reliant on his children for support (Litwin and Zoabi 2010; Brodsky et al. 2013). Their declining social and family status, coupled with maladaptation to the modern lifestyle, has rendered them more vulnerable to mistreatment (Litwin and Zoabi 2004). Another prominent factor commonly associated with the risk of abuse is the subject’s participation in social networks (Lowenstein et al. 2009). Jewish societies are traditionally characterized by extensive social networks, which offer a platform for mutual support (Halperin 2015). However, the change of lifestyle from communal to individualist brought about by modernization has significantly reduced both contact between older Jews and their social networks and the size of such networks, which is a predictor of an elevated risk of social isolation (Lowenstein and Doron 2008). Social isolation, in turn, has been identified as a consistent risk factor for elder mistreatment in various ethnic groups (Dong et al. 2010; Jogerst et al. 2000). Similar to the case of other ethnic groups in the Middle East, Jewish families also attach great importance to the traditional values of familism, collectivism, and patrilineality, which emphasize mutual support among family members and unconditional submission to parental authority (Katz 2009). As a result, older Jews generally hold at least a normative expectation of emotional, instrumental, and financial support from their adult children (Lavee and Katz 2003). As mentioned above, intergenerational relations within Jewish families have undergone a dramatic transformation in recent decades as a result of changes in family structure, lifestyle, and behavioral patterns (Lowenstein et al. 2008) as well as demographic changes such as greater life expectancy and declining fertility rates (Aboderin 2004). Researchers have observed that two conflicting forces challenge the cohesion and solidarity of Jewish families. On the one hand, most older Jews continue to uphold traditional social norms and cultural values, but on the other hand, the younger generation has been gravitating toward modernist and individualist ideologies (Lavee and Katz 2003). As the norms of filial duties and familial obligations become less clearly defined, intergenerational support has become a subject of uncertainty (Katz and Lowenstein 2012). For example, young adults today tend to not conform rigidly with tradition and expectations and provide less instrumental and emotional support to their aged parents compared to the previous generation (Halperin 2013). Meanwhile, changes in the pattern and nature of intergenerational exchange have resulted in the loss of entitlement to unconditional care and security among older Jews, which may increase their susceptibility to emotional distress and mistreatment (Litwin and Zoabi 2004). Family is considered an important building block of Jewish society (Katz and Lowenstein 2003). Traditionally members of Jewish families tend to live close to each other, and frequent in-person contact is common between adult children and their parents (Lowenstein et al. 2008). That being said, co-residence between adult children and their parents has become less common in family-oriented communities (Litwin 2006) in light of the gradual shift in society from traditionalism and collectivism to modernism and individualism (Gliksman and Litwin 2011). This decline, coupled with the increased geographical mobility enjoyed by adult children

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that allows them to pursue opportunities far away from home, may have contributed to the transformation of the nature of caregiving by adult children from obligatory to conditional upon circumstances, such as the availability of time and resource and the actual needs of the parents (Katz and Lowenstein 2012). Instead of personally providing the care required, adult children may enlist the services provided by day-care centers, home-care providers, and long-term care facilities instead (Brodsky et al. 2014). Such substitution, however, often fails to satisfy parents who hold onto traditional expectations of direct support from their children (Silverstein et al. 2013), and intergenerational conflict and abusive relationships may arise as a result (Halperin 2013).

Gender and Elder Abuse Women as Victims East Asia Patriarchy, patrilocality, and patrilineality have always been the main features of family structure in East Asian countries such as China, Japan, and South Korea (Fan 2007; Qian and Sayer 2016) and are responsible for unequal marital relationships, domination by family patriarchs, and biased inheritance systems that favor sons over daughters (Oshio et al. 2013). Women are expected to submit to their fathers, brothers, husbands, and adult sons (Bergren et al. 2016), and it has been suggested that such imbalance of family status and power is why, compared to men, women are more prone to suffering from various types of domestic mistreatment and manipulation (Dong et al. 2007; Lee and Kolomer 2005; Yan and Fang 2017), a pattern that has been observed in studies conducted in China (Dong and Simon 2010), Japan (Kasuga 2004), and South Korea (Nam and Lincoln 2017). Meanwhile, younger women in East Asia have been found to be at risk of adopting abusive behavior toward their parents-in-law, which may be connected with the common practice in East Asia where parents-in-law serve as “cultural gatekeepers” who uphold traditional norms such as filial piety and patriarchal authority (Lan 2002). The resulting family dynamic often leads to rigid genderbased labor division where the married son is sometimes even discouraged by his parents from helping his wife with domestic chores and child-rearing duties, which may lead to resentment – a predictor of perpetuation of abusive behavior – on the part of the daughter-in-law (Shih and Pyke 2010). Chinese and Japanese cultures, guided by the Confucian principles of filial piety, attach great importance to submission to patriarchal authority and the continuation of family lineage (Traphagan 2008; Ng et al. 2002). Daughters-in-law are traditionally expected to live with their husband’s family to provide care and assist with domestic chores (Cong and Silverstein 2008; Kasuga 2004) and are usually considered “temporary members” of the family until they produce a male heir to carry on the family name (Chu et al. 2011). However, over the past few decades, more and more women have adopted modern individualistic values and are unwilling to submit to

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traditional patriarchal norms (Gu et al. 2009). The daughter-in-law may insist on expressing her own opinion instead of submitting to her in-laws (Long et al. 2009; Song and Zhang 2012), which is just one example of the many culture-specific causes of intergenerational discord and poor relationships between in-laws. Failure on the part of the son/husband to mediate also leads often to escalation and ultimately mistreatment and abusive behavior (Soeda and Araki 1999; Shih and Pyke 2010). The distribution of family resources has also been identified as a predictor of conflict and abuse involving daughters-in-law in Mainland Chinese families (Song and Zhang 2012). Traditionally married couples are expected to support the husband’s parents financially, but not the wife’s parents, although they can expect to receive some form of support should they help with child-rearing duties (Silverstein et al. 2007). Problems arise when women are expected to support their husband’s parents, while at the same time are also required to financially support their own parents under elderly protection laws (Gruijters 2018; Chappell and Kusch 2007). The implementation of the one-child policy in the 1970s means many married women today are the only child of their family and have to cope with providing for both their own parents and their husband’s parents without the help from siblings. When the wife, sometimes with the support of her husband, decides to divert part of the couple’s financial resources to her own parents, conflict often arises between her and her in-laws who feel more entitled to such resources under traditional norms (Song and Zhang 2012). This often results in frustration and resentment on the part of the daughter-in-law that can manifest in the form of abusive behavior. Meanwhile, as more and more couples are the product of modern courtship as opposed to arranged marriage, and as women’s socioeconomic status continues to rise, many married couples form stronger bonds between themselves compared with their predecessors and consider themselves, instead of their parents, to be the core of the family. This line of thought has been shown to be another predictor of conflict and abusive relationships between daughters-in-law and their parents-in-law (Yi et al. 2016). In contrast, in South Korea where women are also expected to provide for their husband’s parents often at the expense of neglecting the needs of their own parents (Feldman et al. 2007; Kim et al. 2015), compared with their Mainland Chinese counterparts, South Korean women and their parents appear to be more willing to accept such unequal distribution arrangement and are often able to cope by rationalizing it as part of traditional custom (Fingerman et al. 2012). A different potential cause of elder abuse involving daughters-in-law has been observed in highly developed and westernized East Asian societies such as Hong Kong and Japan, where women have long become part of the workforce and are expected to fulfill the dual roles of breadwinner and family caregiver for aged parents, parents-in-law, and their own children (Lau et al. 2006; Roberts 2016; Long and Harris 2000). Despite the fulfillment of multiple responsibilities, however, daughters-in-law do not enjoy any special status under inheritance laws compared with biological children (Lee 2010). Resentment and a sense of injustice may arise when they are left out of inheritance, which can potentially lead to mistreatment and abusive behavior toward their care recipients (Soeda and Araki 1999).

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South Asia Conservative gender norms are deeply internalized in the patriarchal value systems prevalent in South Asian countries. They often lead to both implicit and explicit discrimination against women in various domains, such as employment, education, and family (Jesmin and Salway 2000; Weitzman 2014; Bhat and Dhruvarajan 2001). For example, in India, Bangladesh, and Nepal, women are often precluded from receiving formal education and employment (Blunch and Das 2015; World Bank 2012; Emran and Shilpi 2010). As a matter of fact, financially independent women are often considered a threat to traditional norms (Weitzman 2014). In the family sphere, men enjoy the power to make major decisions and control family resources (Blunch and Das 2015; Rao et al. 2012), while women are often confined to their husband’s household and contribute through bearing children, carrying out domestic chores, and caring for their parents-in-law, in line with the practices of purdah and virilocality that are prevalent in the region (Anand 2007; Kabeer et al. 2014; Baldassar 2007). Essentially, sons are expected to provide financial support, while daughters-in-law are expected to provide instrumental and emotional support (Jesmin and Salway 2000; Verma et al. 2006). Rigorous adherence to “purdah” and patriarchal authority greatly limits the daughter-in-law’s autonomy in decision-making and the development of social networks outside of her husband’s family and helps perpetuate the cycle of submission to her husband and parents-in-law (Borooah and Sriya 2004; Kabeer et al. 2014; Baldassar 2007). An ideal daughter-in-law is one who submits unconditionally to her parents-in-law and works diligently to satisfy the needs of her husband’s family (Nosaka and Andrews 2004). The great disparity in power is a common cause of mistreatment and abuse committed against daughters-in-law by parents-in-law in India, Nepal, and Bangladesh (Nosaka and Andrews 2004; Ragavan and Iyengar 2017). Such abuse or violence can persist for years as the same customs and social norms often prevent the victims from taking action that can change their circumstance (Emran and Shilpi 2010; Singh 2017). The status of a daughter-in-law cannot improve until her father-in-law either dies or becomes incapacitated, in which event her husband becomes the head of the family (Borooah and Sriya 2004). Until that happens, elder abuse may occur when a daughter-in-law decides to take revenge against actual or perceived ill treatment they receive from their parents-in-law (Farid 2017; Chokkanathan et al. 2014). In India and Bangladesh, such risk appears to be higher in urban areas, where higher costs of living and greater employment opportunities (Ranganathan 2016) draw women away from home (Cooke 2010; Ahmed et al. 2016) and increase the risk of elder neglect. The Middle East Although Middle Eastern states such as Iran, Yemen, Iraq, Qatar, and the United Arab Emirates saw growth in female literacy in recent years, the labor market is still largely dominated by men (Al-Ghanim and Badahdah 2017). One of the biggest obstacles women face when pursuing employment opportunities outside of home is the need to obtain permission from their male family members (Al-Ghanim and Badahdah 2017). While the Arab Spring movement of 2011 did bring some improvement to the social and political status of women in the region, overall their

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rights have remained largely unchanged. Women are still considered inferior to men, and such gender bias extends to the domestic sphere. The patrifocal structure of Middle Eastern families treats women as subordinates (The Arab Human Development Report 2005) and the property of their husband. The patriarch of the family decides how a woman should live her life (Ibrahim 1998), and male family members, including her father, husband, brothers, and even adult sons, have the power to essentially determine her fate (Haghighat 2014). Women enjoy virtually no financial freedom as they are rarely allowed to make their own living and are expected to rely completely on their male family members for financial support (Al-Ghanim and Badahdah 2017). Abandonment by the husband or adult children usually means complete destitution (Gere and Helwig 2012), and the gender-biased inheritance system further forces women to rely on their family (Al-Othman 2011). Rules governing marriages also heavily favor men – a husband has the power to dissolve the marriage at any time and the wife generally has no right to keep the children (Obeid et al. 2010). Even after the death of her husband, a woman still has no freedom to live her own life and must subject herself to her husband’s heirs (Ansari 1995). The mandatory use of veil in public also greatly limits the social life of women and leave them isolated (Haghighat 2014). With gender inequality dominating every aspect of their life, women find themselves in an extremely vulnerable position, which greatly increases their risk of falling victim to abuse as they grow older.

Culture-Specific Forms of Abuse East Asia The prevalence of Confucian values in East Asia has given rise to certain forms of abuse and response that are highly culture-specific. For example, in Chinese societies such as Hong Kong, older adults often consider “being treated as if transparent” as a severe form of abuse (Yan et al. 2015). In South Korea, disrespect and unsatisfactory care are often regarded as major abuse (Chang and Moon 1997). Daughters-in-law are traditionally held to extremely high caregiving standards, and older Koreans tend to consider insufficient care by daughters-in-law as serious mistreatment (Chang and Moon 1997). Other types of behavior by daughters-inlaw that are regarded as elder abuse by older Koreans include “direct expression of disagreement with mother-in-law,” “failure to use certain words or phrases in the Korean language that denote respect,” as well as “failure to acknowledge the elder when he or she arrives at or leaves the residence” (Chang and Moon 1997). Meanwhile, older Japanese adults consider it a form of abuse when they are blamed for problems related to their adult children (Arai 2006). Japan is also unique in that physical abuse is more prevalent compared with other countries in the region (Sasaki et al. 2007), something that has been associated with the traditional acceptance of using violence in conflict resolution and punishment (Okonogi 1994). Confucian philosophy also influences customs relating to inheritance, which attach great importance to the transmission of wealth from one generation to the next (Kim et al. 2015). As a result, adult children in East Asian countries often feel

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they have a vested interest in their parents’ assets and financial resources and do not consider it inappropriate to exploit or manipulate the same and parents tend to tolerate such financial exploitation (Das et al. 2003; Kim et al. 2015). In extreme cases, adult children may be so used to taking everything for granted, to the extent they become oblivious to their parents’ needs, which may give rise to neglect and abuse. Another noteworthy characteristic of elder abuse in East Asia is the challenges that often arise in the detection, investigation, and prosecution of sexual abuse committed against older adults. Due to long-standing cultural taboos on sex-related subjects, they are generally not discussed in public (Dong et al. 2007), and incidents of elder sexual abuse are often not reported due to their association with shame and humiliation (Kozu 1999). In Japan, mass media often employs euphemisms when reporting on sexual abuse – rape becomes “violent act,” and molestation is called “mischievous act” (Fujiwara et al. 2012). This kind of attitude often undermines the public’s awareness of the gravity and serious consequences of sexual assault and makes detection, investigation, and evaluation extremely difficult.

South Asia Older adults in South Asia traditionally enjoy considerable veneration and supreme status in both public and domestic spheres (Bhattarai 2013; Kalavar and Duvvuru 2006). However, as younger generations come under the influence of modern values, they no longer obey their aged parents to the degree expected of them and often lead lifestyles significantly different from those led by previous generations. They also tend to take support from their parents for granted and do not always reciprocate as traditions prescribe (Tara and Ilavarasan 2009). Such behavior is often perceived by older generations as “inappropriate treatment” in violation of parental authority and traditions (Das et al. 2003; Bhattarai 2013). In India, “disrespect and lack of dignified living conditions” is considered by the elderly as major abuse (HelpAge India 2012), and the same goes for “being taken for granted,” “being used as additional domestic help,” and “not being appreciated for contributions made to domestic chores” (Shah et al. 1995). Similar to the case of East Asia, adult sons are traditionally the heir to their parents’ properties and wealth, which often leads to adult sons treating it as their right to appropriate or misuse their parents’ resources, and such exploitative behavior is often accepted, or at least tolerated, by their aged parents (Tareque et al. 2015). Religion also plays a key role in the prevalence of financially exploitative behavior. Older adults who practice Buddhism or Hinduism tend to believe that one should forsake all worldly possessions in preparation for reincarnation or afterlife (Nagaraj et al. 2013), which prompts them to give away all their assets to their children, leaving them in a vulnerable position and prone to mistreatment (Shah et al. 1995). In Bangladesh, crowded living conditions and gender-biased traditions that favor males often lead to persistent spousal abuse that can last for decades (Munsur et al. 2010). It has been noted that women in India, Bangladesh, and Nepal are particularly prone to financial neglect, as they are often deprived of the right to own productive resources, which leads to their financial dependence on their husband and adult sons (Bhattarai 2014; Gautam et al. 2011; Rao et al. 2012).

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Elder abuse in South Asia is particularly worrying due to its tendency to be passed on from one generation to the next (Islam et al. 2017). Given the emphasis tradition places on inheritance and the fact that family members often live in an enclosed environment, elder abuse can be internalized and accepted as a means to resolve family conflict and passed on to younger generations, much like other traditions and domestic practices (Koenig et al. 2003; Chokkanathan and Lee 2005; Niaz 2003).

Middle East Given their differences in terms of religious beliefs and cultural norms, unsurprisingly there are significant differences between Arab and Jewish societies when it comes to the form, extent, and prevalence of elder abuse (Giles et al. 2012; Sohrabzadeh 2010). Jewish societies are more westernized compared to Arab societies and place less emphasis on familial solidarity (Litwin 2004). It is interesting to note that, unlike the case of East Asian societies, where insufficient care is often regarded as mistreatment, in Israel excessive care received from family members is sometimes considered offensive by older Israelis of Jewish origin. It is possible that they treat it as an intrusion of personal autonomy and also do not wish to feel a sense of dependency (Reinhardt et al. 2006). It may also have to do with the fact that in Israel elderly care is often considered a public issue as Jewish societies tend to possess relatively mature and extensive public social support networks and elderly care is generally regarded as a matter of social responsibility (Silverstein et al. 2013). The use of public community facilities and social services is common among older Jewish adults, and as such complaints of elder abuse often revolve around failure on the part of the state to provide satisfactory support and the resulting feeling of being deprived and mistreated (Silverstein et al. 2013; Halperin 2013). As a matter of fact, insufficient support and improper care received from public care providers are considered a major form of abuse (Azaiza and Brodsky 2003). In contrast, older Arabs tend to rely not on public social services but rather on family care, and as such, cases of elder abuse often involve failure on the part of adult children to provide proper care and instrumental and financial support (Lowenstein et al. 2007; Silverstein et al. 2013). Similar to the case of most Asian societies, elder abuse in Arab societies is closely tied to the victim’s gender, with women being over two times more likely to become a victim of domestic abuse (Oveisi et al. 2014). Also noteworthy is the high prevalence of spousal abuse committed by husbands that continues into old age (Ghahhari et al. 2008), possibly a result of patriarchal social values and practices (Saffari et al. 2017).

Culture-Specific Response to Elder Abuse East Asia In East Asia, elder abuse is often treated as a negative private family issue that should not be interfered with by a “third party” that is not a part of the family, and open discussion of the matter can be seen as damaging to the honor of the family (Lee and

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Eaton 2009). This attitude often prevents victims from seeking help or wanting to seek help (Dong et al. 2007; Yan 2015; Lee and Eaton 2009). In addition, elder abuse is generally considered an immoral misconduct that violates the virtue of filial piety (Moon et al. 2001; Shibusawa et al. 2005), and as such the acknowledgment of abuse is often equated with admitting the failure on the part of the adult children to fulfill their filial obligation, which is commonly associated with poor parenting and accordingly is perceived as extremely humiliating (Lee and Eaton 2009). Moreover, in some cases, the abuse remains unreported due to the victim’s fear that a report may trigger domestic conflicts and put the integrity and reputation of the family in jeopardy (Yan and Tang 2001; Kasuga 2004). Ironically, Confucian concepts that are ubiquitous in East Asian cultures, such as filial piety, collectivist familism, patrilineality, and close family ties, despite their emphasis on respect for the elderly, do not reduce the risk of elder abuse but instead only prevent its detection.

South Asia Similar to the case of East Asia, older adults in South Asia are also resistant to the idea of reporting abuse (Kalavar et al. 2013). According to the familist and collectivist values that predominate family interactions in South Asia, abuse against senior family members is generally regarded as immoral misconduct (HelpAge India 2012), and as such, the reporting or acknowledgement of abuse is perceived as equivalent to admitting the existence of family discord and accordingly would bring shame and damage the family name (Chokkanathan and Natarajan 2018; HelpAge International 2013). Another key aspect of elder abuse in South Asia is the general lack of intention on the part of the victim to seek help. Common reasons behind such decision include self-blame, attribution of abuse to the victim’s own past mistake, fear of retaliation or loss of support, fear of damage to family integrity, fear of son’s absence at own funeral (Chokkanathan et al. 2014), perceived inferior social status, as well as lack of knowledge of available resources in the community (Ahmed et al. 2005). Lack of action on the part of the victim often results in repeated and extended abuse and is certainly an issue that needs to be addressed. The Middle East In Middle Eastern societies where collectivist values serve as moral guidelines for social interactions and family relationships, elder abuse is regarded as deviant behavior violating traditional moral codes (Litwin and Zoabi 2003). However, third-party intervention is often turned down as incidents of abuse are generally considered a private matter that should be dealt with by the family itself (Katz and Lowenstein 2012). It is worth noting that the Arab population in this region tends to display a higher level of tolerance toward spousal violence against women. The Quran has been construed as supporting such behavior as a means of disciplining wives guilty of infidelity and bringing dishonor to her family, and the relevant verse is often cited as justification for spousal abuse (Sagot 2005). Given the holy status of the Quran, women suffering from abuse often see their entire community turn against them and

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sometimes are even blamed for causing the abuse by irritating their husband (Saffari et al. 2017). Given their extremely vulnerable position, women often fall victim to repeated abuse. It has been suggested that shari‘a-based marital laws may have aggravated the problem (Reynolds 2015), and most female victims of domestic violence tend to stay in abusive relationships due to fear of losing child custody or financial support from their husband and the cultural stigma attached to divorced women (Saffari et al. 2017). Given the prevalence of the issue in the region, routine screening for domestic violence in clinical, healthcare, or community setting is crucial in preventing spousal abuse, which if left unresolved may evolve into elder abuse as the victim reaches advanced age (Faramarzi et al. 2005).

Social Responses Elder abuse was regarded in many Asian societies in the past as a taboo subject that should not be discussed openly, that is, until the past two decades when it was finally recognized as a social issue and measures were put into place to facilitate detection, evaluation, investigation, and intervention. The period also saw an increase in media coverage on the subject, legislative reforms, and the development of systems and databases by social service agencies to collect case information to aid research on the subject (Shankardass 2013). Significant progress has been made in countries including China, South Korea, Japan, India, Singapore, Bangladesh, Malaysia, and Israel in addressing the subject of elder abuse and developing effective intervention methods (Jamaluddin et al. 2015; Shankardass 2013) since the Second World Assembly on Aging, the first concerted effort by the international community to draw attention to the subject and encourage governments to develop and fund national programs to detect, prevent, and stop elder abuse (United Nations 2002). Since then initiatives made by the international community have prompted countries to prioritize elderly protection on their national agenda via policy and legal reform, public awareness campaigns, and the development of intervention strategies and social services designed to lower the risk of elder abuse (Nerenberg 2006). Since 2006, many governments and civil organizations in Asia began observing World Elder Abuse Awareness Day, an initiative put forth by the International Network for the Prevention of Elder Abuse (Shankardass 2013).

Key Points • Elder abuse is a pressing concern for Asian countries as many of them are aging rapidly. • Traditional values such as filial piety and collective familism, patrilineality, and parental authority continue to shape the filial expectations of older generations in the Asian societies. Changing economic and social circumstances,

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sociodemographics, and population mobility, however, may limit the younger generation’s actual practice of filial obligations. Mismatch in expectations may result in intergenerational conflicts. • Older Asians observe cultural specific forms of elder abuse such as disrespect, unsatisfactory care, being taken for granted or used as domestic help, or not being appreciated. • Abuse victims are reluctant to discuss experience of abuse out of fear of retaliation, loss of financial support, disruption of familial harmony, damage to family reputation, and social stigma. • In the past two decades, Asian countries have begun to recognize elder abuse as a social issue. Measures were put into place to facilitate detection, evaluation, investigation, and intervention. Significant progress has been made in countries including China, South Korea, Japan, India, Singapore, Bangladesh, Malaysia, and Israel in addressing the subject of elder abuse and developing effective intervention methods.

Summary and Conclusion A considerable number of academic studies on elder abuse have been made worldwide over the past decades and have greatly improved our understanding of the problem and its associated factors and consequences. However, Asia remains comparatively underrepresented in this body of literature, which limits our understanding of the issue in the context of Asian cultures. Research has shown that cultural sensitivity is essential in studies that examine the issue in Asia. As discussed above, older adults in Asia tend to interpret elder abuse differently due to their unique traditions and cultural expectations. Therefore, it is necessary to conduct in-depth interviews to acquire a better understanding of culture-specific types of abuse and develop culturally sensitive assessment tools. Instruments that are able to measure culture-specific forms of abuse while also allowing cross-culture comparison should be developed (Yan et al. 2015). To more effectively combat the challenge caused by the general reluctance on the part of older adults in Asia to discuss experience of abuse out of fear of retaliation, loss of financial support, disruption of familial harmony, damage to family reputation, and social stigma (Yan and Fang 2017), steps should be taken to establish a positive rapport with subjects during interviews. On the other hand, routine screening for abuse in clinical or community setting can also facilitate timely detection and intervention. As older Asian adults are often reluctant to share their experience of abuse to anyone outside their family or social circles, it may be helpful to extend the scope of prevention and intervention strategies to cover their social networks (Yan and Fang 2017). On the community level, public awareness campaigns, education programs, comprehensive reporting systems, and support programs that are culturally sensitive can all help reduce potential risk factors. For data collection, the use of vignette and witness accounts may prove to be a helpful alternative to traditional methods that focus on personal accounts.

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It is important to pay attention to the fact that while Asian cultures tend to share similar values such as familism, filial piety, collectivism, patrilineality, and intergenerational exchange, communities are often made up of various ethnic and religious groups each with its own distinct cultural heritage. Levels of exposure to social changes and modernization may also vary. Therefore, researchers should avoid overgeneralization and pay attention to not only the similarities shared by different groups but also the differences that set them apart. In addition, as Asia continues to undergo urbanization and modernization against the backdrop of globalization, it is important for researchers to take into account the constantly evolving political and economic landscapes that more often than not have profound effects on family interactions and intergenerational relationships. Elder abuse is a global public health and human right issue. In order to effectively combat this problem, concerted efforts between clinicians, scholars, social workers, and policy makers are essential.

Cross-References ▶ Caregiving and Elder Abuse: A Complex Relationship ▶ Intersectionality of Elder Abuse and Mental Health Issues: Needs and Interventions for Victims ▶ Introduction: Abuse in Later Life

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Caregiving and Elder Abuse: A Complex Relationship

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Georgia J. Anetzberger

Contents Introduction: “Do families really do these things?!” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Definitions: “The neighbors thought I was awful. They condemned me, because I hit an old man” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Elder Caregiving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Interface of Caregiving and Elder Abuse: “You need to be around for a whole day to see what it’s like” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Historical Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Caregiving as Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A Portrait of Caregiving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Current State of Knowledge: “[Caregiving] was expected of me since childhood. I feel like I was programmed for this purpose” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevalence and Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevention and Intervention: “I don’t want anyone’s help. I have my family. It’s not easy, but we’re all each other has” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points: “I change her and she does it again. I tell her I’ll spank her if she don’t stop” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusions: “He’s dead. Thank God” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. G. J. Anetzberger (*) School of Medicine and Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, OH, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_114

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Abstract

Elder abuse and caregiving have a complex relationship. Caregiving once was seen as the primary cause of the problem, especially as perpetrated by family members, but also in other arrangements, where assisting frail or impaired older adults was regarded as so stressful and burdensome that mistreatment resulted. Since limited research supported this viewpoint, caregiving has come to be regarded more as a context than cause of abuse occurrence. This chapter examines these perceptions along with presenting caregiving and elder abuse definitions and variations, explanatory theories, and key research on the nature, scope, and consequences of the interface between caregiving and elder abuse. Case studies occasionally are used to clarify and illuminate select study findings. The chapter also includes a description of existing systems, programs, and services to prevent and respond to elder abuse within the caregiving context. Finally, it concludes with recommendations for future research and the need for practice innovations in this area. Keywords

Elder abuse · Elder caregiving · Informal caregiver · Formal caregiver · Victim characteristics · Perpetrator characteristics · Prevalence · Prevention · Intervention

Introduction: “Do families really do these things?!” Caregiving for vulnerable older adults is a worldwide phenomenon. It is typically an intergenerational expectation and cultural value. Yet both caregiving and care receiving can be difficult, with potential implications for the individuals involved and society as a whole. Indeed, in the minds of some, there seems to be a kind of link between elder caregiving and possible elder abuse that spans settings and both informal and formal relations. Accordingly, when assisting an impaired older adult becomes too stressful and burdensome, elder abuse may be an unfortunate byproduct. According to one abusing caregiver, “That’s the trouble with old people. You can’t make them understand.” For another abusing caregiver, “[My mother] was always a problem for me.” The purpose of this chapter is to examine caregiving and elder abuse as a complex relationship rather than inevitably intertwined. Chapter sections begin with actual statements made by abusing caregivers (Anetzberger 1987), as they reveal their feelings about the act of caregiving and the older adult as care recipient. Available research is presented as the dynamics and dimensions of the complex relationship are revealed. Then resources are identified that might assist caregivers in fulfilling their helping role and perhaps prevent elder abuse occurrence or reoccurrence.

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Key Definitions: “The neighbors thought I was awful. They condemned me, because I hit an old man” Elder Caregiving Elder caregiving generally refers to providing an array of possible assistance to an older adult (with age of onset no less than 50 years) with a chronic illness, disability, or serious health condition. Definitions of the concept tend to differ by dimensions of assistance provided, mainly: • Type: From personal care (referred to as activities of daily living, like eating and toileting) to emotional support and companionship • Length: From long term (such as when the care recipient has Alzheimer’s disease or a behavioral disorder that spans many years or even decades) to short term (such as following a hip fracture or stroke) • Amount: From multiple tasks to a single task • Time devoted: From 21 or more hours weekly (intense caregiving) to only an hour or two weekly Elder caregiving is typically categorized by relationship and setting. Types of relationship are informal and formal. Informal caregivers are usually family members (particularly spouses/partners, adult children, or grandchildren) but also may be friends, neighbors, or close associates from membership organizations in which the care recipient belongs, such as religious institutions or social clubs. Formal caregivers are providers connected to a service organization, like a home care agency or assisted living facility. Although either relationship category may be monetarily compensated for care provided, ordinarily informal sources act voluntarily without pay, and formal sources require payment. Motivations for providing uncompensated care vary but include family or civic duty and affection or gratitude for the care recipient. Types of setting are domestic and residential. Private homes and apartments illustrate domestic settings, whether owned or rented by the care recipient, caregiver, or some other personal relation. Nursing facilities and group homes exemplify residential settings. Although most care provided in residential settings comes from formal sources, such as nurses and nursing assistants, informal caregivers may remain involved, usually in reduced capacities than when the care recipient lived in the community. The same applies when formal caregivers, like social workers and home health aides, offer assistance in domestic settings. Informal caregivers typically do not fully relinquish their helping role, although specific tasks and level of involvement may change.

Elder Abuse There is no universally accepted definition of elder abuse. However, several sources offer definitions that have received more agreement and use than others. Foremost

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among the sources are the National Research Council, World Health Organization, Elder Justice Roadmap, Centers for Disease Control and Prevention, and National Center on Elder Abuse. Figure 1 delineates the elder abuse definition of each identified source. Within the framework of caregiving and elder abuse, the definitions offered by these sources are consistent in three ways: • Caregivers are specifically named as potential elder abuse perpetrators or included under the broader relationship description of “trusted others.” • Elder abuse may be inflicted either intentionally or unintentionally, the latter illustrated by negligent acts or failure to appropriately act. • Inflicted abuse either causes or creates risk of harm to an older adult, including failing to satisfy basic needs or to provide essential protection. The above definitional sources further reveal various forms of elder abuse. Consistent among them are physical abuse, sexual abuse, financial abuse/exploitation, emotional/ psychological abuse, and neglect. Some sources also include abandonment as a separate form. Neglect and abandonment are the only forms where by definition the perpetrator must be a caregiver rather than some other trusted person. It is noteworthy that polyvictimization is common in elder abuse situations, with neglect often occurring with other elder abuse forms (Roberto 2017). Definitions of elder abuse forms differ by source. Figure 2 illustrates the variation, considering those given by the Centers for Disease Control and Prevention and National Center for Elder Abuse. Legal definitions of elder abuse at the federal level tend to require that infliction be knowing or willful, as is evident in those of the Older Americans Act, Violence Against Women Act, and Elder Justice Act. State adult protective service (APS) laws vary in this regard, among others, but generally recognize both intended and unintended acts as constituting elder abuse. In addition, while most APS laws use global definitions for elder abuse, state criminal statutes tend to be more specific. For example, abuse or physical abuse in APS law may be reflected in the criminal code under such offenses as assault, battery, domestic violence, manslaughter, or murder (Stiegel 2014). Restricting elder abuse, especially neglect, to acts of commission eliminates unintended and accidental acts by caregivers. It is unknown how much elder abuse actually represents acts of omission, but it may be significant, since the origins rest with such factors as caregiver ignorance, inexperience, lack of resources, or burden.

The Interface of Caregiving and Elder Abuse: “You need to be around for a whole day to see what it’s like” Historical Perspectives Discussion of abuse, neglect, or exploitation with older adults as victims began with the development of APS and attempts at nursing home reform during the 1960s. At the time concern was less with caregivers as perpetrators than the systemic changes required to protect impaired and vulnerable older adults living alone in the

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National Research Council: “Mistreatment. (a) Intentional actions that cause harm or create a serious risk of harm, whether or not intended, to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder, or (b) failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm.” World Health Organization: “Elder abuse is a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person.” www.who.int/en/newsroom/fact-sheets/detail/elder-abuse Elder Justice Roadmap: “Elder abuse ‘includes physical, sexual or psychological abuse, as well as neglect, abandonment, and financial exploitation of an older person by another person or entity, that occurs in any setting (e.g., home, community, or facility), either in a relationship where there is an expectation trust and/or when an older person is targeted based on age or disability’.” Center for Disease Control and Prevention: “Elder abuse is an intentional act, or failure to act, by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult.” https://www.cdc.gov/violenceprevention/elderabuse/definitions.html National Center on Elder Abuse: “Domestic elder abuse generally refers to any of the following types of mistreatment that are committed by someone with whom the elder has a special relationship (for example, a spouse, sibling, child, friend, or caregiver). Institutional abuse generally refers to any of the following types of mistreatment

occurring in residential facilities (such as a nursing home, assisted living facility, group home, board and care facility, foster home, etc.) and is usually perpetrated by someone with a legal or contractual obligation to provide some element of care or protection.” http://ncea.acl.gov/faq/index.html Fig. 1 Elder abuse definitions

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Center for Disease Control and Prevention:

• “Physical Abuse: the intentional use of physical force that results in acute or chronic illness, bodily injury, physical pain, functional impairment, distress, or death. Physical abuse may include, but is not limited to, violent acts such as striking (with or without an object or weapon), hitting, beating, scratching, biting, choking, suffocation, pushing, shoving, shaking, slapping, kicking, stomping, pinching, and burning.

• Sexual Abuse or Abusive Sexual Contact: forced or unwanted sexual interaction (touching and non-touching acts) of any kind with an older adult. This may include forced or unwanted:  Completed or attempted contact between the penis and the vulva or the penis and the anus involving penetration  Contact between the mouth and the penis, vulva, or anus  Penetration of the anal or genital opening of another person by a hand, finger or other object  Intentional touching, either directly or through the clothing, of the genitalia, anus, groin, breast, inner thigh, or buttocks These acts also qualify as sexual abuse if they are committed against a person who is not competent to give informed approval.

• Emotional or Psychological Abuse: verbal or nonverbal behavior that results in the infliction of anguish, mental pain, fear, or distress. Examples include

behaviors intended to humiliate (e.g., calling names or insults), threaten (e.g., expressing an intent to initiate nursing home placement), isolate (e.g., seclusion from family or friends), or control (e.g., prohibiting or limiting access to transportation, telephone, money, or other resources). Fig. 2 (continued)

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• Neglect: failure by a caregiver or other responsible person to protect an elder from harm, or the failure to meet needs for essential medical care, nutrition, hydration, hygiene, clothing, basic activities of daily living or shelter, which results in a serious risk of compromised health and safety. Examples include not providing adequate nutrition, hygiene, clothing, shelter, or access to necessary health care; or failure to prevent exposure to unsafe activities and environments.

• Financial Abuse or Exploitation: the illegal, unauthorized, or improper use of an older individual’s resources by a caregiver or other person in a trusting relationship, for the benefit of someone other than the older individual. This includes depriving an older person of rightful access to, information about, or use of, personal benefits, resources, belongings, or assets. Examples include forgery, misuse or theft of money or possessions, use of coercion or deception to surrender finances or property, or improper use of guardianship or power of attorney.” https://www.cdc.gov/violenceprevention/elderabuse/definitions.html National Center on Elder Abuse:

• “Physical Abuse—Inflicting, or threatening to inflict physical pain or injury on a vulnerable elder or depriving them of a basic need.

• Emotional Abuse—Inflicting mental pain, anguish, or distress on an elder person through verbal or nonverbal acts.

• Sexual abuse—Non-consensual sexual contact of any kind, coercing an elder to witness sexual behaviors.

• Exploitation—Illegal taking, misuse, or concealment of funds, property, or assets of a vulnerable elder.

• Neglect—Refusal or failure by those responsible to provide food, shelter, health care or protection for a vulnerable elder.

• Abandonment—The desertion of a vulnerable elder by anyone who has assumed the responsibility for care or custody of that person.” http://ncea,acl.gov/faq/index.html

Fig. 2 Definitions of elder abuse forms

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community and lacking nearby supportive family or else languishing in nursing homes deemed ill-equipped or ill-inclined to provide necessary assistance. The following quotations from professionals concerned about the population during that decade reflect prevailing perspectives. Speaking at the tenth Anniversary Meeting of the National Council on the Aging in New York City in 1960, Mildred Barry of the Welfare Federation in Cleveland, Ohio, defined in three parts those older people in need of protective services (Barry 1960, p. 1): (a) An older person who is alone and/or without a responsible person to act in his behalf and unable to provide himself with proper or necessary subsistence, medical care, or other care necessary for his health, either through his own means or by a voluntary application to an agency for support and/or care. (b) An older person who requires the special care made necessary by his mental condition, whether or not the person requires commitment or guardianship. (c) An older person who lacks the proper care or engages in a situation dangerous to life or limb or injurious to the health or morals of himself or others and refuses voluntary aid to correct his condition. Speaking at a hearing of the US Senate in Washington, D.C., in 1969, Mother Bernadette of Saint Joseph Manor in Trumbull, Connecticut, described conditions faced by most older adults residing in nursing homes: The Eskimos used to freeze their old people to death; we bury ours alive. Maybe the Eskimos were more merciful than we are. Ask the old people in nursing homes across the country. A fast death is a blessing we deny them. Yet we deny them a human life too. For these people life is an endless succession of deprivations. The food is poor and there’s not enough of it. A typical dinner at one Medicare approved home consisted of one chicken wing and a scoop of dried up mashed potatoes. Unsanitary conditions, lack of medical care, uncaring, sometimes deliberately cruel attendants. Lack of even the barest safety precautions against fire or accident, are all facts of life for these patients. Perhaps worst of all, there is nothing to do—day in and day out—but wait for death to come.

More than a decade would pass before caregivers began to be recognized as potential elder abuse perpetrators. This awareness came with the earliest research and Congressional testimony on elder abuse as an aspect of family violence in the late 1970s. Lau and Kosberg (1978) examined 404 older adult cases seen by a social services agency affiliated with a Cleveland hospital during a calendar year, discovering that 39 had suffered some form of elder abuse, usually neglect or psychological abuse. All perpetrators were informal caregivers, with adult children the most likely to be abusive. Similarly, Steinmetz (1979), in Congressional testimony, described elder abuse situations she had uncovered as a family violence researcher to be analogous to those of child abuse situations, where a dependent care recipient can be a source of caregiver stress, burden, and mistreatment. Nearly a decade later, Steinmetz (1988) conducted research on the subject. In a sample of 104 caregivers and 119 older adult kin care recipients, 23 caregivers admitted using physical abuse

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to control the care recipient, with 46% of variance explaining elder abuse found among 7 dependency and stress variables, such as elders who used verbal abuse and invaded the caregiver’s privacy. It is likely that the above inaugural research and testimony provided foundation for early belief that caregiver stress and burden represented the primary cause for elder abuse occurrence. Evidence that it was embraced as dominant etiology can be found in the earliest federal government summary of public testimony and research on elder abuse. Before presenting a laundry list of possible explanations, it concluded: “. . .a major precipitating factor is family stress. Meeting the daily needs of a frail, dependent elderly relative may be an intolerable burden for family members” (US Select Committee on Aging 1981, p. 59). By the late 1980s, there had occurred a shift away from caregiver stress and burden as the dominant explanation for domestic elder abuse that remains today. In part the movement reflected accumulating research suggesting that elder abuse etiology was multifaceted and caregiver stress and burden were not dominant risk factors (Anetzberger 2000). Additionally, the field of elder abuse came to be led by professionals in health care, criminal justice, and domestic violence programming rather than social workers and sociologists (Anetzberger 2018). They saw the problem through different lenses, as a medical syndrome, public health concern, and crime. With changing perspectives, focus on the perpetrator as a stressed and burdened caregiver seemed to fade, and perpetrators increasingly were called upon to be accountable for their abusive actions through penalty, rehabilitation, and the like. Brandl and Raymond (2012) further articulate the meaning and potential implications of this shift in stating, “Seeing caregiver stress as a primary cause of abuse has unintended and detrimental consequences that affect the efforts to end this widespread problem. . .Some consequences include blaming of the victim, minimizing offender accountability, and devaluing social action that responds to the problem of elder abuse. . .such as victim-centered services and inter-disciplinary training and interventions (pp. 32, 35, 37).” Moving from elder abuse in the community to elder abuse in institutions reveals a different evolution in explaining the occurrence of mistreatment. Elder abuse in nursing homes since the 1970s, when the earliest exposes were published, has been seen resulting more from owner/operator greed, fraud, and mismanagement along with government indifference and lack of oversight than direct care worker stress and burden (e.g., Mendelson 1974). Even when direct service workers are acknowledged and their stress and burden are seen as a concern, attention quickly seems to turn to other levels within the institution and outside it for change, as evident from a respondent plea in an early investigation of resident abuse: “the problem [cause of abuse] is daily high stress situations. The administration must understand and be more realistic about how we can handle and have to handle situations day after day” (MacNamara 1988, p. 38). Calls for systemic reform have resulted in sweeping changes to federal regulation and strengthening the roles of nursing home ombudsmen and surveyors (Hirschel and Anetzberger 2012). Still the problem remains. Efforts to hold direct care workers accountable exist, such as through state criminal codes and abuser registries.

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However, the prevailing viewpoint of etiology and change remains focused on systems rather than individuals, somewhat in contrast to elder abuse in the community.

Caregiving as Context As discussed elsewhere by Anetzberger (2000), caregiving is a context for the occurrence of elder abuse, but it is not the only one. Other contexts include intimate relations between older spouses and partners, cohabitations of older parents and adult children, and situations wherein trusted workers perform home repairs or other tasks for vulnerable older adults and are left alone with exposed valuables. Context is important in explaining elder abuse, because it brings together the perpetrator and victim and provides the dynamics that can foster abuse occurrence. However, context alone does not result in elder abuse. Rather, elder abuse is a function primarily of characteristics of the perpetrator and secondarily of characteristics of the victim, as illustrated in Fig. 3 Explanatory Model for Elder Abuse. The research literature on elder abuse risk factors suggests that salient characteristics of the perpetrator include mental disorders, substance abuse, housing or financial dependence, caregiver stress and burden, negative attitudes about older adults, and being a witness or victim to childhood family violence. Salient characteristics of the victim include being female, physical health problems or frailty, cognitive impairment, dementia, lower income, and inadequate social support (Johannesen and LoGiudice 2013; Chen and Dong 2017). Research using APS assessment data resulted in the categorization of elder abuse perpetrators into four distinct profiles: caregiver, temperamental, dependent caregiver, and dangerous. Among them, caregivers were found to be the least harmful and most supportive of victims. Across seven negative characteristics or behaviors, such as being in trouble with the law and having a drinking problem, caregivers were the lowest in six. They also were most likely to help the victim with personal needs and give emotional support (DeLiema et al. 2018). Risk factors for elder abuse can vary by caregiving relationship and setting. For example, besides correlates already cited, a study of elder abuse reported by home visiting nurses found mistreated patients more likely than non-mistreated patients to live with others, enjoy high life satisfaction, and be dependent on medication management (Friedman et al. 2015). Moreover, research on risk factors for elder abuse in nursing homes found higher incidents in larger facilities, with higher numbers of residents and increasing demands upon staff (Girard 2011). Long-term care ombudsman identifies additional risk factors for nursing homes, including lack of adequate screening in staff hiring, insufficient training in abuse prevention, poor supervision, and disengaged administration (Miller 2012). It is interesting to note that the research literature indicates there is some overlap between risk factors leading to stress, burden, or other negative consequences of caregiving and risk factors for elder abuse across relationships and settings.

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Primary considerations

Secondary considerations

Characteristics of perpetrator

Characteristics of victim

Context for victim-perpetrator interaction

Context for abuse occurrence

Abuse (Anetzberger 2000) Fig. 3 Explanatory model for elder abuse

Although there may not be a causal link between the two, the overlap in risk factors is suggestive that for some people caregiving can prove to be so difficult that undertaking it may adversely affect the caregiver and/or care recipient, leading to ill health, harm, or even death. Overlapping risk factors associated with the abusing caregiver include poor physical health, anger or hostility, ambivalence about caregiving, depression, and substance abuse. Overlapping risk factors associated with the care recipient/victim include advanced old age, dementia, mental illness, aggression, behavioral problems (e.g., agitation, wandering), and a high level of dependency. Finally, overlapping risk factors associated with the relationship between abusing caregiver and care recipient/victim include poor past relations with the other person, shared living arrangements, unrealistic expectations of the other person, and lack of social support (perceived or actual). These overlapping risk factors further argue for caregiving as a viable context for elder abuse occurrence.

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Various dimensions of and influences on caregiving can challenge caregiver/care recipient interactions and may increase the likelihood of abuse occurrence. Caregiving dimensions can include the recipient’s service needs, such as their type and duration, as well as the caregiver’s qualifications, such as skills and coping ability. Caregiving influences are exemplified by old resentments, new conflicts, and loss of time and privacy that come with contact between caregiver and care recipient. Some of these risk factors, dimensions, and influences are evident in the case study of Erma and Gertrude. Erma is in her early 80s. Five years ago she was hospitalized by a stroke, which left her partially paralyzed with some cognitive impairment and considerable difficulty talking. Since then she lives with her only child, Gertrude, who is widowed and has trouble working outside of the home due to anxiety. No other family members reside nearby, and neither Erma nor Gertrude has many visitors. Gertrude is happy to help her mother unless or until Erma fails to do as she is told, such as refusing to take a bath or eat food placed before her. Gertrude regards these acts as willful and defiant and potentially reflective of her as a caregiver. When they persist, Gertrude becomes angry and has forced compliance, initially by verbal threats and ultimately through physical action, twice thrusting Erma’s face into the food and once shoving her into the tub. Gertrude is only somewhat bothered by this. After all when she was a child and dependent, Gertrude was expected to mind Erma. Disobedience was never an option. Now the situation is reversed, and Gertrude expects the same from her mother.

A Portrait of Caregiving Gertrude may be abusive, but in other ways she reflects and contributes to the profile of caregiving by informal providers in the United States. A large-scale probabilitybased study conducted by the National Alliance for Caregiving and AARP Public Policy Institute (2015) estimated that more than 34 million adults over age 50 received past year unpaid care from another adult, resulting in a prevalence rate of 14.3%. The majority of caregivers surveyed were female (60%) and middle-aged (49 years on average). They cared for a relative (85%), usually a parent or parent-inlaw (49%), and have done so for an average of 4 years. Typically care was provided in the care recipient’s own home (48%) or the caregiver’s household (35%), but sometimes it was extended in a residential setting (11%) or someone else’s home (6%). The average caregiver offered 24.4 h of assistance weekly, but nearly onequarter of study participants gave 41 or more hours, particularly spouses or partners. Half of the caregivers indicated that the care recipients also had assistance from another unpaid caregiver, and one-third reported additional assistance from a paid caregiver. When asked about the impact of caregiving, 22% said that it made their health worse, 28% that it left them highly stressed, 18% that it resulted in high financial strain, and 61% that it required making work accommodations. The literature on caregiving suggests impact variation by such factors as caregiver gender and type of assistance (He et al. 2018). It also evidences that caring for an older adult with dementia or behavioral disorders is particularly stressful and

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burdensome (e.g., Dassel and Carr 2016). Caregivers identify as problematic symptoms like physical assaults, psychosocial aggression, inappropriate sexual behaviors, wandering, sleep disturbances, and resisting assistance by the care recipient. Impaired older adults also worry about the impact of caregiving on the person doing it, with one study showing that seven in ten care recipients are very or somewhat concerned about being a burden (Nieuwenhuis et al. 2018). Overall informal caregiving is more difficult today than in the past. In 1900, when the average lifespan was 47, people usually died early from acute illness or trauma, needing assistance ordinarily only intermittently and for short periods of time. Today, when the average lifespan is nearly 80, people generally die late, following multiple chronic conditions, which may require complex care on a long-term basis. In 1900, just 41% of persons survived to age 65; today 84% do (Arias 2014). From the perspective of the older adult care recipient, in 1900 that person most likely lived in a multigenerational household with more than one available female relative able to provide needed help. Today that same individual is more likely to live alone with limited, if any, nearby family support. Those available to help probably will find caregiving more challenging, since now most women are in the workforce and advances in health care require complex informal caregiving, such as medication management and operating machinery, with minimal guidance and support (Feinberg and Levine 2015–2016). May lives in a nursing home. She was transferred there a few months ago from an assisted living facility, wherein she had resided for several years. During her long stay, she made friends and become accustomed to the ebb and flow of life there. Then one day facility staff said that her care needs and forgetfulness had increased, requiring her to move, with arrangements quickly following. May had found adjusting to the new setting hard. She knew no one, and meeting new people was difficult, given her current limitations. The routines were unfamiliar, which often left her confused and anxious. Worse was the frequency in which addressing her care needs was delayed or even overlooked. When asked, staff would attribute it to personnel turnover and shortages. However, among themselves they talked about “demanding residents,” “unrealistic expectations,” and “people whose complaints only made things worse.” After being yelled at and threatened following a couple of complaints, May learned to stay quiet. As a result, the reality of life in a nursing home became call lights may not receive a response, incontinence pads may go unchanged for a day or more, and meals may be served without accompanying assistance. Just as the situation of informal caregiving can be challenging, as May’s story suggests, so too can that of formal caregiving; most is done by direct care workers in domestic or residential settings. Direct care workers are the primary source of paid hands-on care for older adults requiring long-term care. They include nursing assistants, home health aides, personal care aides, and psychiatric assistants. Direct care workers represent among those occupations in highest demand in the United States. There was a need for approximately 2.3 million FTE direct care workers in 2015 that will climb to over 3.4 million by 2030. Because the majority of older adults with long-term care needs live in the community, half of the

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workforce demand is in home- and community-based settings, with one-quarter each in residential care facilities and nursing homes (US Department of Health and Human Services 2017). Barriers to meeting the demand for direct care workers include low wages, few benefits, inadequate transportation, exhausting schedules and client needs, insufficient training, poor career opportunities, and lack of recognition and respect. Research suggests that issues faced by direct care workers can have profound implications on quality of life for these workers and potentially those they serve. For instance, a national survey of nursing assistants found that low wages meant that one-third of workers were on some kind of means-based public assistance and nearly half of uninsured workers could not afford an employer-sponsored plan (Squillace et al. 2009). Moreover, nursing assistants themselves describe their work as “repetitive, taxing, and demeaning [wherein they] are treated as unreliable and easily replaceable” (Bishop 2014, p. 546). The concerns of informal and formal caregivers are not new, and many seem enduring, despite efforts to recognize and address them. In 2008 the National Academies Institute of Medicine published Retooling for an Aging America: Building the Health Care Workforce, which included recommendations for enhancing the ability of informal and formal care providers to respond to a doubling of the older adult population by 2030. Ten years later Gerontological Society of America Policy Advisor Brian Lindberg (2018) assessed progress made by 31 organizations working collaboratively to implement the recommendations and thereby strengthen the elder care workforce. Despite noteworthy successes, he concluded that there remain “many recommendations that still are relevant to our work” (p. 5), including increasing the recruitment and retention of care providers, better preparing informal caregivers for elder care, widening duties and responsibilities of workers at varied training levels, and paying elder care specialties higher salaries and wages.

Current State of Knowledge: “[Caregiving] was expected of me since childhood. I feel like I was programmed for this purpose” Theory It is widely acknowledged in the field of elder abuse that theoretical development lags behind empirical study, with some arguing that it is because of the overuse of caregiver stress models to explain the problem (e.g., National Institute of Justice 2014). Certainly there are three major shortcomings of elder abuse theory to date. First, the elder abuse field has tended to borrow theory from other fields, particularly other abused populations, even when differences between elder abuse, child abuse, and intimate partner violence diminish the usefulness of borrowed theory. Second, given the complexity of elder abuse – its multiple forms, settings, and involved parties – it is unlikely that any single theoretical approach will suffice. Finally, although some theories have received limited support through empirical study, no approach has been rigorously tested.

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Among the dozens of theories advanced to explain elder abuse, several seem applicable to elder caregiving. Among them, some appear more relevant to mistreatment in domestic settings and others to residential settings. Four illustrative theories for each type of setting are identified in Fig. 4. A brief description is included, especially as it might inform caregiving and elder abuse, recognizing that verification of appropriateness and use has yet to be determined.

Prevalence and Reporting A recent systematic review and first meta-analysis of the elder abuse prevalence literature resulted in 15.7% as pooled global frequency or approximately 1 in 6 or 41 million community-dwelling persons age 60 and over having experienced the problem during the past year (Yon et al. 2017). The most common forms in order of reported frequency were psychological abuse, financial abuse, neglect, physical abuse, and sexual abuse. There was no prevalence difference between older women and older men. However, there was variation by continent, with elder abuse more common in Asia (20.2%) and Europe (15.4%) than in the Americas (11.7%). Also, within-continent variation was more extreme than between-continent variation. For example, among the countries comprising the Americas, prevalence rates ranged from 10% to 79.9%, with the lowest rate for the United States. Turning to elder abuse and caregiving, a somewhat earlier systematic review of the literature on global prevalence discovered that nearly one-fourth of older adults (per country range of 11–62%) dependent on caregivers reported having experienced psychological abuse and one-fifth reported neglect (Cooper et al. 2008). This study also found that when asked, family caregivers and direct care workers generally were willing to report abuse. In addition, the first large-scale nationally representative survey of elder caregivers revealed that over one-third reported that they had engaged in potentially harmful behaviors toward their care recipients during the prior 3 months, typically psychological abuse. The most common examples were using a harsh tone, insulting, swearing, screaming, or yelling at the victim or threatening to place the victim in a nursing home or to stop providing care to the person (Lafferty et al. 2016). As indicated earlier, mistreatment tends to be a particular problem for older adults with dementia. A review of more than two dozen related studies uncovered prevalence rates for elder abuse forms ranging from 27.9% to 62.3% for psychological abuse and 3.5%–23.1% for physical abuse, with 31% of community-dwelling caredependent victims experiencing multiple forms (Dong et al. 2014). Based upon National Elder Mistreatment Study findings, the prevalence of domestic elder abuse in the United States is said to approximate 10%, experienced by about five million persons annually, with financial abuse and potential neglect by family members the most common forms (Acierno et al. 2010). Perpetrators were more likely to be spouses/partners than either children/grandchildren or other relatives, except for neglect where children/grandchildren were most likely. The study also found that older adults who had greater need for assistance were more likely

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Domestic Settings Communication theory: Abuse results from dysfunctional communication between caregivers and care recipients, such as when older adults are noncompliant or exhibit troubling behaviors. Role theory: Mistreatment results when caregivers are inappropriate, unable, or unwilling to provide needed assistance to older adults. Functualism: Abuse exists because cultural norms leave few choices outside of the family for elder caregiving. Strain theory: Mistreatment can result in situations wherein elder caregivers experience high levels of burden, such as when they are ill-prepared for the role and related responsibilities. Residential Settings Situational theory: There are insufficient measures taken in nursing homes to prevent elder abuse, such as the use of property identification or surveillance systems. Control theory: Direct care workers in nursing homes are more likely to commit elder abuse when their social bonds are weak, like when they are new to the job or have ageist attitudes. Social exchange theory: Abusive direct care workers see themselves as unfairly treated in their relationship with residents or other nursing home staff and resort to mistreatment to obtain or restore the power balance. Wicked problem approach: Elder abuse is reoccurring and enduring in nursing homes because solutions to reducing it and improving care can cause further problems in service provision. Fig. 4 Possible theories for caregiving and elder abuse

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than those who did not to experience verbal abuse by caregivers, but not physical abuse, sexual abuse, or neglect. Still, the actual reporting of elder abuse situations to APS or other systems able to offer help seems to be quite low, an estimated of only 1 in 24, with even lower rates for neglect and financial abuse (Lachs and Berman 2011). There is less known about the prevalence of elder abuse by formal caregivers whether in domestic or residential settings. Existing studies mainly reflect interviews with relatives or facility/agency staff. In addition, data are available from organizations responsible for handling complaints or reports of the problem. Collectively they suggest that elder abuse by formal caregivers is far from unusual. More specifically, in a rare comparison of elder abuse by paid formal caregivers across settings, investigators surveying the relatives of care recipients found that nursing homes had higher rates of all abuse forms than either home care or assisted living, even after adjusting for the older adult’s health conditions. Moreover, neglect was the most common form and sexual abuse the least (Page et al. 2009). Focusing on nursing homes, a survey of care staff revealed that nearly half had inflicted elder abuse, again typically neglect, during the past year (Natan and Lowenstein 2010). Indeed, 7% of facility complaints to long-term care ombudsmen and 27% of reports to Medicaid Fraud Units involve elder abuse (Daly 2017).

Consequences The consequences of elder abuse by caregivers can be examined in multiple ways, such as its meaning to victims and perpetrators (illustrated in the quotations following each chapter heading); the problem’s effect on personal, physical, mental, or financial health; and the implications of elder abuse occurrence for society in terms of factors like service use and cost. None of these has been sufficiently studied, with the main research deficits surrounding the consequences for society and perpetrators, including those who are caregivers. Rather, research to date has tended to cross victim/perpetrator relationship contexts, with a focus on the effects of elder abuse on victims. After reviewing the related literature, Podneiks and Thomas (2017) categorize the consequences for victims in terms of greater mortality, diminished physical and mental health, and more hospital visits and institutionalization. The physical health effects include injuries, disabilities, high blood pressure, heart problems, digestive troubles, and physical malaise. The mental health effects include depression, anxiety, posttraumatic stress disorder, irritability, and cognitive impairment. Once again, however, the consequences of elder abuse occurrence are greater for victims with dementia. In addition, the consequences of elder abuse can be more far reaching than the above categories suggest. In a nationally representative, large-scale study, Breckman et al. (2018) found that among those who knew a relative, friend, or neighbor who had experienced elder abuse by a caregiver, two-thirds reported high levels of personal distress. Further, Jackson (2018) discusses the potential negative effects of elder abuse interventions, with, for example, APS investigations sometimes resulting in restrictions of personal freedom for the victim, like changed residence or the imposition of guardianship.

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Prevention and Intervention: “I don’t want anyone’s help. I have my family. It’s not easy, but we’re all each other has” There is a lack of empirical evidence to demonstrate which practices (and their accompanying policies) work and which do not work in effectively preventing or treating elder abuse, whether it is occurring in a caregiving or some other context. Concern about this deficit recently has resulted in priority given to such studies through both funding initiatives, such as those undertaken by the National Institute of Justice and Administration on Community Living, as well as action agendas, including the US Department of Justice’s “Elder Justice Roadmap” and “Building Consensus on Research Priorities in Elder Mistreatment.” Indeed, the conclusions are discouraging from the few systematic reviews undertaken on elder abuse interventions, whether general or program-specific. For example, Ploeg et al. (2009) found that qualifying evaluations of elder abuse interventions failed to reduce abuse reoccurrence or significantly affect either care resolution or at-risk caregiver outcomes. Looking at APS alone, the only nationwide program exclusively concerned with elder abuse, Ernst et al. (2014) concluded, “Missing, but critically needed, is research that reveals the effectiveness, or lack thereof, of specific interventions provided by APS workers” (p. 487). The absence of evaluative findings to support particular programs and services has not hampered their institutionalization and spread. Indeed, several response systems are found nationwide. Their identity and functions related to elder abuse victims and caregiving perpetrators are delineated on Fig. 5. As evident from its content, most elder abuse practice to date focuses on intervention rather than prevention. This perhaps reflects the early consideration of elder abuse primarily as a social problem, medical syndrome, or crime, where response after abuse occurrence is paramount. Only lately has elder abuse also come to be regarded as public health and human rights concerns, where efforts at prevention are emphasized. In addition, most elder abuse interventions target the victim. If the perpetrator is considered at all, it is typically to punish or otherwise hold actionable his or her abusive behavior. For instance, as Fig. 5 indicates, state APS law requires workers to direct their attention to the needs of elder abuse victims. Consequently they rarely offer services to perpetrators, even those who provide care. Yet, some early elder abuse research suggests that perpetrators may be more willing to accept help than victims and more likely to benefit from help received (Anetzberger 2005). No specific program or service for elder abuse perpetrators has been developed (Jackson 2018). This means that what exists more generally targets caregivers in order to support their role, improve their health and quality of life, or prevent stress and burden. If they also prevent or treat elder abuse by caregivers, this is good but it is not the intent, and there is no research attesting to their effectiveness in this regard. A sampling of programs and services targeting caregivers is found on Fig. 6, and those targeting care recipients but also potentially benefitting caregivers are found on Fig. 7. In reviewing the lists, it is important to note that like elder abuse interventions, most caregiver interventions have not been shown through research to impact the well-being of caregivers (Peacock 2003). Moreover, when asked which kinds of

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Adult protective services (APS)

Long-term care ombudsman (LTCO)

Aging Network

Fig. 5 (continued)

Functions targeting elder abuse victims In compliance with state law, APS receives and investigates reports or referrals of elder abuse, evaluates client status and service needs, provides or arranges services to address actual or potential harm to victims, and seeks legal intervention, if required Operating out of federal and state law, LTCO receives, investigates, and attempts to resolve complaints (including those of elder abuse) regarding consumers of formal care in residential and sometimes domestic settings. LTCO provides clients with possible ways to resolve identified problems and acts as a client/victim advocate, if that person gives permission Under authority of the Older Americans Act, state units on aging and regional area agencies on aging work to prevent elder abuse through such means as public awareness activities and ensuring that a wide range of nutrition, supportive, and other services are available locally to foster the well-being, safety, and connection of older persons, like congregate and home-delivered meals, home care, legal services, and transportation

4651 Functions targeting caregivers as actual or potential elder abuse perpetrators State law does not mandate assessment or assistance for caregiving perpetrators, but it may be offered to prevent elder abuse reoccurrence when appropriate interventions are available either through the APS auspice or another community agency LTCO assists formal caregiving perpetrators only indirectly, when individual client complaint resolution suggests the need for facility or systemic change, for example, through staff education or new protocol adoption

The Older Americans Act directs the Aging Network to implement the Eldercare Locator and National Family Caregiver Support Programs, which together offer such services as information and referral, support groups, training, and respite care

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Law enforcement/victim services

Domestic violence and sexual assault programs

State department of health

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Law enforcement/victim services often is the first response in victim crisis situations (including elder abuse), may offer well-being checks on impaired older adults, and provides help and compensation for victims These programs seek to empower victims (usually women) and ensure their safety through hotlines, information and referral, emergency shelters, safety planning, legal advocacy, counseling, and transitional housing

Following federal and state laws, health departments receive and substantiate elder abuse by formal care providers in licensed care facilities

Law enforcement addresses legal code violations, arresting, prosecuting, and punishing perpetrators as well as enforcing protective and restraining orders

Efforts are made to hold perpetrators accountable for their violence through the justice system. Some programs offer direct services to perpetrators toward changing their abusive behaviors or aggravating conditions, such as counseling and substance abuse treatment Health departments can bar abuse perpetrators from working in licensed care facilities

Fig. 5 Key response systems for elder abuse victims and caregiving perpetrators

assistance would be most helpful, caregivers prioritize tax relief, monetary subsidies, and respite (National Alliance for Caregiving and AARP 2015). Also, when surveyed, caregivers are found to most likely use the following interventions: assistive devices, personal or nursing care, home modification services, and homemaking (Hong 2010). Finally, a study where abusive caregivers were asked which interventions would help prevent abuse found priority was given to a combination of services targeting the caregiver directly and indirectly, including advisce on better handling memory problems of the care recipient, home care, respite, and companionship services (Selwood et al. 2009).

Key Points: “I change her and she does it again. I tell her I’ll spank her if she don’t stop” • Elder caregiving and elder abuse represent complex concepts, characterized by multiple possible forms, relations, and settings. • The perceived interface of caregiving and elder abuse may have begun in the 1960s, but it began to intensify in the late 1970s; following early research and

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Caregiver assessment Counseling and behavioral health services Education (e.g., articles, websites) Financial assistance (e.g., employee benefits, tax relief) Health prevention strategies (e.g., improved coping skills, relaxation techniques) Information and referral (e.g., Family Caregiver Alliance Family Care Navigator, National Association of Area Agencies on Aging Elder Locator) Respite (e.g., adult day services, residential respite) Self-help and support groups Technology (e.g., alerting devices, motorized lifts) Training (e.g., anger management, dementia care)

Fig. 6 Programs and services that target caregivers

•

• • •

•

Congressional testimony on the subject, wherein caregivers emerged as likely perpetrators, it was thought largely due to the stress and burden of assisting impaired older adults. Caregiving is most appropriately seen as one of several likely contexts for elder abuse occurrence (rather than the cause of the problem), associated primarily with characteristics (risk factors) of the perpetrator and secondarily with those of the victim. Elder caregiving may be given by informal or formal providers, but both can be adversely affected by its demands, particularly when the care recipient has dementia. Among the many theories advanced to explain elder abuse, several relate to elder caregiving, although to date none have been substantiated. It is suggested that more than one-fourth of care-dependent older adults in domestic settings globally experience some form of elder abuse in the past year, with research indicating that the problem is likely more common in residential settings, especially nursing homes. The consequences of elder abuse for victims can range from diminished physical and mental health to greater mortality.

4654 Fig. 7 Programs and services targeting care recipients that also can benefit caregivers

G. J. Anetzberger Case management Chore services Companionship programs Friendly visiting Home-delivered meals Homemaking Legal and financial planning Nursing Personal care Relocation assistance Telephone reassurance

• Thus far, no specific system, program, or service has been shown empirically to be effective in preventing or treating elder abuse, including situations involving abusing caregivers. • Although no program or service exists for elder abuse perpetrators, there are those that target caregivers directly or indirectly in order to improve their well-being or reduce stress and burden, and these also may help prevent or treat elder abuse by caregivers.

Summary and Conclusions: “He’s dead. Thank God” The chapter began by defining what some might consider divergent and incompatible concepts – elder caregiving and elder abuse. Yet, during the history of elder abuse recognition and response, the two often have been linked, resulting in a belief that elder caregiving, at least when stressful and burdensome, is the primary cause of elder abuse. Thus far there is insufficient theoretical and empirical justification for this belief, but still remnants of it remain. It is the premise of this chapter that while caregiving has not been shown to be the cause of elder abuse, caregiving can be an important context for its occurrence.

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There seem to be three circumstances when the likelihood of abuse occurrence is heightened in this context, and all require further investigation: (1) when characteristics of the abusing caregiver are incompatible with successful assumption of the caregiving role, such as when that person has serious mental illness, substance abuse, or history of hostility or violence; (2) when characteristics of the care recipient result in behaviors seen as difficult or troublesome by the caregiver, such as agitation, aggression, or wandering due to dementia; and (3) when the interaction between the caregiver and care recipient is compromised, as can happen with a long history of poor relations or insufficient social contact or support. Although there is compelling need for research to determine more specifically the connection between elder caregiving and elder abuse, woefully insufficient are studies with the abusing caregivers as subjects. Yet, without fully understanding their needs and perspectives, it is impossible to design interventions effectively targeting them. Ultimately the absence of systems, programs, and services capable of preventing and treating elder abuse in a caregiver context can leave abusing caregivers to manage on their own with potential dire result, as illustrated by the last caption for this chapter and begins this section. Surely a better resolution than this must be found and made available.

Cross-References ▶ Intersectionality of Elder Abuse and Mental Health Issues: Needs and Interventions for Victims ▶ Introduction: Abuse in Later Life ▶ Mothers’ Perspectives on Abuse by Adult Children ▶ Perpetrators of Elder Abuse ▶ Systems Responses to Older Adult and Elder Abuse

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Barry, M. (1960). Workshop on protective services: Cleveland’s proposal for older people. Paper presented at the annual meeting of the National Council on the Aging, New York. Bishop, C. E. (2014). High-performance workplace practices in nursing homes: An economic perspective. The Gerontologist, 54(S1), 546–552. Brandl, B., & Raymond, J. A. (2012). Policy implications of recognizing that caregiver stress is not the primary cause of elder abuse. Generations, 36(3), 32–39. Breckman, R., Burnes, D., Ross, S., Marshall, P. C., Suitor, J. J., Lachs, M. S., & Pillemer, K. (2018). When helping hurts: Non-abusing family, friends and neighbors in the lives of elder mistreatment victims. The Gerontologist, 58(4), 719–723. Chen, R., & Dong, X. (2017). Risk factors of elder abuse. In X. Dong (Ed.), Elder abuse: Research, practice and policy (pp. 93–107). Cham: Springer International Publishing. Cooper, C., Selwood, A., & Livingston, G. (2008). The prevalence of elder abuse and neglect: A systemic review. Age and Ageing, 37, 151–160. Daly, J. M. (2017). Elder abuse in long term care and assisted living settings. In X. Dong (Ed.), Elder abuse: Research, practice and policy (pp. 67–91). Cham: Springer International Publishing. Dassel, K. B., & Carr, D. C. (2016). Does dementia caregiving accelerate frailty? Findings from the health and retirement study. The Gerontologist, 56(3), 444–450. DeLiema, M., Yonashiro-Cho, J., Gassoumis, Z. D., Yon, Y., & Conrad, K. J. (2018). Using latent class analysis to identify profiles of elder abuse perpetrators. Journals of Gerontology: Social Sciences, 73(5), e49–e58. Dong, X., Chen, R., & Simon, M. (2014). Elder abuse and dementia: A review of the research and health policy. Health Affairs, 33(4), 642–649. Ernst, J. S., Ramsey-Klawsnik, H., Schillerstrom, J. E., Dayton, C., Mixson, P., & Counihan, M. (2014). Informing evidence-based practice: A review of research analyzing adult protective services data. Journal of Elder Abuse & Neglect, 26(5), 458–494. Feinberg, L. F., & Levine, C. (2015–2016). Family caregiving; looking to the future. Generations, 39(4), 11–20. Friedman, B., Santos, E. J., Liebel, D. V., Russ, A. J., & Conwell, Y. (2015). Longitudinal prevalence and correlates of elder mistreatment among older adults receiving home visiting nursing. Journal of Elder Abuse & Neglect, 27(1), 34–64. Girard, N. J. (2011). Factors that affect abuse of older people in nursing homes. AORN Journal, 94(4), 420–421. He, W., Weingartner, R. M., & Sayer, L. C. (2018, February). Subjective well-being of eldercare providers: 2012–2013. Washington: US Census Bureau and National Institute on Aging. Hirschel, A. E., & Anetzberger, G. J. (2012). Evaluating and enhancing federal responses to abuse and neglect in long-term care facilities. Public Health & Aging Report, 22(1), 22–27. Hong, S. I. (2010). Understanding patterns of service utilization among informal caregivers of community older adults. The Gerontologist, 50(1), 87–99. Jackson, S. L. (2018). Understanding elder abuse: A clinician’s guide. Washington, DC: American Psychological Association. Johannesen, M., & LoGiudice, D. (2013). Elder abuse: A systematic review of risk factors in community-dwelling elders. Age and Ageing, 42(3), 292–298. Lachs, M., & Berman, J. (2011, May). Under the radar: New York State elder abuse prevalence study: Self-reported prevalence and documented case surveys: Final report. New York: Lifespan of Greater Rochester, Inc., Weill Cornell Medical Center of Cornell University, and New York City Department for the Aging. Lafferty, A., Fealy, G., Downes, C., & Drennan, J. (2016). The prevalence of potentially abusive behaviors in family caregiving: Findings from a national survey of family carers of older people. Age and Ageing, 45, 703–707. Lau, E.E., & Kosberg, J.I. (1978). Abuse of the elderly by informal care providers. Paper presented at the annual scientific meeting of the Gerontological Society of America, Dallas. Lindberg, B.W. (2018, April). Ten years later: Revisiting the eldercare workforce report. Gerontology News, pp. 4–5.

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Jo Anne Sirey, Maria Minor, and Jacquelin Berman

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Perpetrator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Victim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A Promising Intervention for Victims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

As the aging population grows, the number of older adult victims of abuse with mental health needs increases. This creates a need for elder abuse interventions that collaboratively target abuse and mental health to reduce victimization. According to the World Health Organization, over 20% of adults aged 60 and over suffer from a mental or neurological disorder; depression and anxiety are the most prevalent mental health issues in this population. With depression, comes the heightened risk of suicide with high rates of suicide especially among older men (CDC). Mental health need adds an additional layer of complexity, to the

J. A. Sirey (*) Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA e-mail: [email protected] M. Minor Weill Cornell Medical College, New York, NY, USA e-mail: [email protected] J. Berman New York City Department for the Aging, New York, NY, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_115

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already complex and multidimensional area of elder abuse. Among perpetrators, mental health and substance abuse problems are common (Jackson, Int J Offender Ther Comp Criminol 60(3):265–285, 2016; Johannesen and LoGiudice, Age Ageing 42(3):292–298, 2013; Labrum and Solomon, Psychiatric Q, 89(1):117–128, 2018). Among victims, mental health problems are both risk factors for abuse (Beach et al., Gerontologist 50(6):744–757, 2010) and consequences of abuse (Csoff et al., Gesundheitswesen 76(6):e23–31, 2014; Wu et al., PLoS One 7(3):e33857, 2012). In our own research, more than a third (34%) of victims with capacity seeking services reported significant depression or anxiety (Sirey et al., Am J Geriatr Psychiatry, 24(4):310–319, 2016). To begin to explore the impact of mental health on elder abuse, we will provide a brief review the intersectionality of elder abuse with mental health and substance abuse among both victims and perpetrators with an emphasis reviewing the available research and interventions. We conclude with a review of the research on a specific mental health intervention designed for victims (PROTECT). Keywords

Elder abuse · Mental health · Depression · Interventions

Introduction According to the Center for Disease Control (CDC), the most common mental health conditions in older adults involve mood disorders, such as depression and bipolar disorder, anxiety, and cognitive impairment. The World Health Organization (WHO) reports that globally more than 300 million people suffer from depression and nearly as many report anxiety disorders (Depression and Other Common Mental Disorders: Global Health Estimates 2017). Older adults, both men and women, are at higher risk for completed suicide in many countries (Conwell 2011). However, the rates of depression vary based on how it is assessed, and the population. Older adults with greater medical burden and/or functional impairment have higher rates of mental health disorders. The WHO reports that the highest rate of depression globally is among women aged 55–74 (7.5%). As the older adult population grows, unmet mental health needs for this demographic increase. In the United States according to the US Census Bureau, 21% of the population is 65 years of age, with older adults aged 85 and older as the fastest growing subgroup (ACS 2016 1-year estimates, US Bureau of Census). Looking at service use to help identify need, 15% of Fee for Service Medicare recipients had a diagnosis of depression and had significantly higher medical costs (Alexandre et al. 2016). Untreated depression in older adults is associated with increased rates of suicide (Conwell et al. 2010), nonsuicidal mortality (Gallo et al. 2005), risk of falling (Byers et al. 2008; Eggermont et al. 2012), and disability (Murray et al. 2013). Even mild depression takes a significant toll on quality of life (QALY) among older adults (Jia and Lubetkin 2017). Depression treatment is as effective in decreasing symptoms as it is in younger adults, and has

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been useful in improving functioning (Alexopoulos et al. 2016; Marino et al. 2008) and reducing mortality in the elderly. Anxiety disorders among the elderly is estimated to affect 3.8% globally (Mental Health of Older Adults, World Health Organization 2017) with estimates from the Institute on Health estimating that anxiety could impact as much as 14% of individuals in a given year (National Institute of Health 2010). However, most older adults with mental health needs do not receive the appropriate services, and in fact most older adults with anxiety and depressive disorders do not obtain treatment (Barry et al. 2012; Byers et al. 2012; Olfson et al. 2016). In the United States, the majority of adults (73.3%) who receive treatment for depression are seen in primary care settings, with the majority of patients (87%) receiving pharmacotherapy (Olfson et al. 2016). Older adults rarely receive psychotherapy for depression (Olfson et al. 2016), even though they may prefer it as a treatment modality to avoid taking multiple medications and unwanted side effects (Areán et al. 2001). The unmet need for mental health services for older adults burdened with mental disorders such as anxiety and depression leaves many older adults at increased risk for morbidity and mortality as a result (Conwell 2018). Mental health need adds an additional layer of complexity to the already complex and multidimensional issue of elder abuse. The literature supports that poor mental health for both the perpetrator and the victim is associated with increased likelihood of abuse happening (Pillemer et al. 2016). Among perpetrators, mental health and substance abuse problems are common (Jackson 2016). Among victims, mental health problems are both risk factors for (Mosqueda et al. 2016) and consequences of abuse (Csoff et al. 2014; Wu et al. 2012). In our own research, more than a third (34%) of victims with capacity reported clinically significant depression or anxiety (Sirey et al. 2016). With the backdrop of the current situation of unmet mental health need for older adults, victims of elder abuse are at an even greater disadvantage requiring better integrated services that collaboratively target abuse and mental health to reduce victimization. In this chapter, we will review the research on the interface of mental health and elder abuse and the promising interventions to target the mental health needs of victims. Several theories on elder abuse aid in our conceptualization of the relationship between mental health and elder abuse. The ecological model first described by Schiamberg and Gans (1999) held that elder abuse comprises multiple domains, each nested within the subsequently higher level of society (NRC 2003; Schiamberg and Gans 1999). Further frameworks have been developed that integrate risk factors and extensive clinical data from victims, such as the NAS Sociocultural Framework and the Abuse Intervention Model, incorporated principles from family violence and criminology theory in addition to the ecological model (Hamby et al. 2014; Mosqueda et al. 2016). These frameworks emphasize the characteristics of the older adult which impart vulnerability to abuse such as mental illness, the characteristics of the trusted other which increase the likelihood of perpetrating abuse such as mental illness or substance abuse, and risky components of the context in which these individuals live such as social isolation. These theories point to the role that poor mental health plays in increasing the likelihood of abuse and the potential impact of abuse on victims.

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The Perpetrator In a systematic review of large, population-based, and cross-sectional studies, mental illness and substance abuse are two of the strongest risk factors among perpetrators correlated with elder abuse (Pillemer et al. 2016). Perpetrators often have poor psychological health, notably depression and anxiety (Pot et al. 1996; Sethi et al. 2011; Wiglesworth et al. 2010). The early literature on the relationship of depression among caregivers presents evidence that clinical depression is a predictive factor of abusive behaviors with older adult care recipients (Beach et al. 2005; Coyne et al. 1993; Paveza et al. 1992; VandeWeerd et al. 2006; Williamson and Shaffer 2001). Approximately 25 to 35% of elder abuse perpetrators suffer from a serious mental illness (Amstadter et al. 2011; Brownell et al. 2000; Clancy et al. 2011; Jackson and Hafemeister 2011; Lowenstein et al. 2009), and perpetrators have more psychiatric hospitalizations than individuals who are not perpetrators of elder abuse (Pillemer and Finkelhor 1988). Unfortunately, one of the limitations in the current literature is a lack of disaggregation when examining types of mental illness among abusers. Most previous research combines disorders ranging from schizophrenia, bipolar disorder, with depression and anxiety. There is a need for future research to develop a more granular approach when examining mental health disorders among perpetrators. Serious and Persistent Mental Illness (SPMI) is used to describe a variety of mental health conditions where ongoing treatment is needed. Often individuals with SPMI suffer from significant social and psychological difficulties. Treatment often combines both medication management and talk therapy. However, treatment can be quite effective and individuals staying on medication protocols can find that symptoms are minimized and they can function normally. There have been a number of studies which have identified associations of mental illness of the perpetrator in relation to specific types of mistreatment. It is important when looking at these studies to keep in mind that relationships found generally concern individuals with serious mental illness who are not treatment compliant. Acierno et al., as reported in The National Elder Mistreatment Study, found that a history of mental illness among abusers was significantly associated with both physical and psychological abuse (Acierno et al. 2009). Labrum found high levels of psychiatric disorders among abusers. However, there were differential rates when looking at abusers suffering from mental illness, with 42% of victims experiencing psychological abuse, 20% of victims experiencing financial exploitation, and 15% of victims suffering from physical abuse, all by relatives with psychiatric disorders (Labrum and Solomon 2018). In addition to mental illness, perpetrator risk factors included, gambling problems, having criminal records, social isolation, being a care recipient, history of childhood family violence, and substance abuse (O’Keeffe et al. 2007; Jackson and Hafemeister 2011; Acierno et al. 2009; Amstadter et al. 2011). Risk factors often varied based on the type of mistreatment. For example, while O’Keeffe et al. found that in general 1% of abusers had gambling problems, this increased substantially when looking specifically at victims of financial exploitation where 23% of the perpetrators exhibited gambling problems (O’Keeffe et al. 2007). Studies have indicated that approximately 25% of perpetrators had a criminal record at the time

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of the abuse, with no differences found among types of mistreatment (Jackson and Hafemeister 2011). While just over one-third of abusers have been shown as being dependent upon their victim for care, differences emerged when looking at type of mistreatment, with 25% of financial exploitation and 39% psychological abuse perpetrators being care recipients (O’Keeffe et al. 2007). Substance abuse has also been shown to be a significant issue among a large percentage of perpetrators. In a New York City sample, 51% of abusers were substance or alcohol abusers (Brownell et al. 2000). In addition to mental health need, multiple studies have correlated abusive behavior with substance misuse (Anetzberger et al. 1994; Homer and Gilleard 1990; Naughton et al. 2010; O’Keeffe et al. 2007; Podnieks 1993; von Heydrich et al. 2012; Wolf and Pillemer 1989). In fact, about 20% to 50% of elder abuse perpetrators were reported to exhibit substance abuse (Amstadter et al. 2011; Brownell et al. 2000; Clancy et al. 2011; Jackson and Hafemeister 2011; Labrum and Solomon 2018; Lowenstein et al. 2009; Naughton et al. 2012). In a more recent study, substance abuse rates vary depending on the type of abuse (Jackson 2016). For instance, in a study by Acierno et al. (2009), 50% of physical, 28% of sexual, and 21% of emotional abuse perpetrators had substance abuse difficulties (Acierno et al. 2009). The roles of dependency and social isolation have been documented to impact elder abuse. There are several relationship factors, which may lead to increased risk of elder abuse. The first is an adult child dependent on the older adult parent for financial, emotional, and/or housing support. In these situations, the adult child often has a history of addiction (Jogerst et al. 2012), mental/emotional illness (Acierno et al. 2009), and/or chronic unemployment (Jackson and Hafemeister 2011). Another perpetrator-dyad relationship type is an older adult parent dependent on the adult child for care (Amstadter et al. 2011; Beach et al. 2005). The interpersonal approach and caregiver stress theory posit providing care for a dependent older adult can increase the risk of caregiver stress and burnout (Jackson and Hafemeister 2013). The final type of perpetrator-dyad relationship, supported by the backgroundsituational theory from dyad discourse theory, is one of a history of family violence (Jackson and Hafemeister 2013). Nearly half (44%) of perpetrators of elder abuse had a history of childhood family violence (Jackson and Hafemeister 2011). Theories on the cycle of violence suggest that violence is learned and is transferred through modeling; this theory provides an additional etiology of elder abuse for a dyad with a history of domestic violence (Jackson and Hafemeister 2013). A substantial minority of elder abuse perpetrators (35%) expressed a lack of social interaction and of relational support (Jackson and Hafemeister 2011). By type of abuse, 53% of sexual, 44% of physical, and 40% of emotional elder abuse perpetrators reported having fewer than three friends (Acierno et al. 2009). This social isolation may be related to the psychopathology of the perpetrator as discussed earlier (Jackson and Hafemeister 2010). Roberto notes that much more information is needed to understand perpetrators as little information is gathered directly from the perpetrators, especially those who commit multiple incidents of abuse (Roberto 2017). The resulting absence of a comprehensive knowledge base hampers

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development of preventive practices and interventions aimed at identifying and working with perpetrators of multiple forms of abuse and ultimately protecting older adults.

The Victim Among victims, mental health problems are both risk factors for abuse (Beach et al. 2010) and consequences of abuse (Csoff et al. 2014; Wu et al. 2012). Across studies globally, greater rates of poor mental and emotional health were seen among elder abuse victims (Giraldo-Rodríguez and Rosas-Carrasco 2013; Naughton et al. 2010). Particularly, depression, anxiety, and PTSD have been found to be the most prevalent psychological consequences of elder abuse (Dong et al. 2013). Morbidity and mortality have been associated with psychological distress. Elder abuse victims with lower levels of psychosocial wellbeing, as defined by depression and limited social network and engagement, were at a particularly increased risk for mortality (Dong et al. 2011). Abuse victims more often experience depression and depressive symptoms compared to older adults without reported abuse (Acierno et al. 2018; O’Keeffe et al. 2007; Podnieks 1993; Wu et al. 2012) and in longitudinal studies the depression appears more enduring. In a telephone survey of community adults (aged 60+), both financial exploitation and psychological mistreatment were associated with depressive symptoms (Beach et al. 2010). Further, a population-based study in China found that older adults who were mistreated had significantly higher rates of depressive symptoms (31.6% vs. 6.8%) and suicidal ideation (16.4% vs. 3.4%) than nonmistreated older adults (Wu et al. 2012). In the ABUEL study (“Abuse of the Elderly in Europe”), violence in the past 12 months is a risk factor for anxiety (OR: 2.25, 95% CI: 1.32–3.84) and depression (OR: 2.27, 95% CI: 1.27–4.04) among adults 60–84 years in Germany (Csoff et al. 2014). In the CHAP study, depressed older victims had higher mortality risk than those victims without depressive symptoms (Dong et al. 2011). In our own research, the New York City Department for the Aging in Collaboration with Weill Cornell Institute for Geriatric Psychiatry implemented one of the first systematic screening for depression and anxiety in an elder abuse service to evaluate both rates of depression and to examine the impact of an intervention to improve mental health outcomes. We found that 34% of victims with capacity reported significant depression or anxiety (Sirey et al. 2016). Among victims screening positive for depression, 53% of victims met criteria for posttraumatic stress sisorder (PTSD) using the PCL symptom assessment (Blanchard et al. 1996) to evaluate DSM-V criteria of PTSD according to the National Center for PTSD. Victims with depression and PTSD reported significantly higher suicidal ideation (40% vs. 18.2%) (Sirey et al. 2018). They were more likely to report multiple types of abuse (3 types). Higher rates of PTSD were reported among victims of emotional mistreatment (84.6% vs. 52.4%) and physical mistreatment (46.2% vs. 23.8%). This research collaboration both demonstrated the importance of integrating mental

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health screening into elder abuse settings and the high rates of mental health need in this vulnerable population. Lastly, in terms of context, social isolation increases the vulnerability for abuse and exacerbates the consequences of abuse. Acierno et al. (2009) found that the perception of low social support more than triples the likelihood that an older adult reported abuse (Acierno et al. 2009). National Elder Mistreatment Study showed that low social support was significantly associated with different types of abuse: emotional, physical, sexual, and potential neglect (Acierno et al. 2010). In a systematic review of population-based studies, Pillemer et al. (2016) report that social support is a protective factor against elder abuse (Pillemer et al. 2016). In a recent population-based study, lower social support and larger social networks were simultaneously associated with higher risk for financial exploitation. This work helps refine our understanding of the protective value of truly supportive individuals and the risk of large networks and “new friends” (Beach et al. 2018). Mental health status for both the perpetrator and the victim of elder abuse is integrally tied to abuse. Future research is needed to examine the causes and mechanisms of abuse, though theories adapted to the field provide a framework for considering the varied etiologies and mechanisms of elder abuse. Poor mental health for the perpetrators predisposes them to abusive behaviors, resulting in harm, compromised care and safety, and instability for older adults. The older adult victims of abuse are then at risk for mental health sequela of abuse such as depression, anxiety and PTSD. One can examine victimization through a trauma informed lens. Traditional elder abuse definitions do not often capture considerations of consequences of earlier life trauma. Trauma can include both directly being a victim or witnessing events, such as violence, a natural disaster, war, death of a loved one, or being diagnosed with a serious health condition. It has been shown that early life trauma is a risk factor for elder abuse (Maschi et al. 2013). These conditions complicate the situation and may add barriers to seeking protective services or taking steps to alter the abusive situations. Further, poor mental health status for older adults can lead to dependence or interpersonal difficulties, increasing susceptibility to abuse. In order to reduce victimization, it follows that mental health must be considered.

A Promising Intervention for Victims The high rate of need and the detrimental consequence of mental health difficulties among abuse victims support the need for targeted mental health services integrated into abuse resolution services. This view is echoed by the thought leaders within elder abuse who argue that there is a need to develop intervention programs addressing both elder abuse and psychopathology (Dong et al. 2013) and that what is needed is more than just support groups. And yet, few programs exist to address depression and anxiety among victims of abuse to improve mental health, even fewer have built in evaluations to determine their impact. PROTECT is a mental health intervention that is designed to provide training to integrate depression

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screening and strategies to make referrals to elder abuse service agencies and to offer a targeted brief therapy to improve depression. The program was designed collaboratively by the New York City Department for the Aging and Weill Cornell Institute for Geriatric Psychiatry to specifically target the needs of victims and the agencies that serve them (Sirey et al. 2015a, b). PROTECT stands for PRoviding Options To Elderly Clients Together. The PROTECT intervention combines psychoeducation and behavioral interventions for depression and anxiety support (if needed). To our knowledge, this is the first behavioral intervention for victims of abuse that has been manualized and evaluated using independent outcome assessments. One of the major barriers to conducting research with this population is a lack of collaboration between different aging service networks that can provide specialized and complementary resources. The PROTECT intervention includes working directly with agencies to help them learn to screen, make a mental health referral, and coordinate with the mental health provider. The PROTECT therapy begins with a clinical evaluation to determine its fit for the needs of the victims. We offer the therapy to victims who screen positive for depression (using the PHQ-9) as a way of identifying those victims with current distress. Victims are very heterogeneous and vary in their mental health needs. We meet victims in a safe space, sometimes in a public location like a library or senior center, or a fast food location, like a McDonalds. This protects both the client and the staff member. The therapeutic sessions (8–9 in total) begin with an overview and orientation to the interface of abuse and mental health symptoms, without presuming etiology. The victim and therapist work to set achievable goals and identify pleasurable activities. Each week an action plan is created that includes steps towards the goal and pleasurable activities. The therapy is focused on the here and now to improve actions that increase rewarding activities and decrease depression by building and implementing action plans. The initial research using a problemsolving teaching approach to PROTECT demonstrated that PROTECT reduced the depression severity in 91% of patients to below the clinically significant level (PHQ-9 < 10) with an average of 57% reduction in depressive symptoms; in addition, the majority of PROTECT clients report having “most or all” of their needs met (Sirey et al. 2015b). PROTECT has been recognized as the 2016 Winner of the Aging Innovations Award in the Elder Abuse Prevention category from the National Association of Area Agencies on Aging (n4a). We have also begun to examine the impact of PROTECT on elder abuse outcomes. While defining outcomes in an elder abuse situation is challenging, we found that victims perceived the abusive situation to be meaningfully improved at follow-up. In our initial sample, 76.9% of physical abuse, 64.7% of financial abuse, and 63.6% of verbal abuse victims felt that the mistreatment has gotten better since participating in the program (Sirey 2019). We understand the impact to be the result of the combination of mental health and elder abuse services. More recent research funded by the National Institute of Mental Health (P50 MH113838, PI: GS Alexopoulos) has tested the intervention in a pilot randomized controlled trial comparing PROTECT to a referral control condition. While the pilot

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project is small (N ¼ 40 with 24 ¼ PROTECT, 16 ¼ Control) in a mixed-effects model, we found that clients who participated in PROTECT had a significant reduction in depression severity (MADRS scores) over time (F[2,61] ¼ 36.37, p < 0.001). Post hoc comparisons showed superiority of PROTECT over the Referral condition in weeks 6 (t, df ¼ 76 ¼ 2.87, p ¼ 0.005) and 9 (t, df ¼ 74 ¼ 2.09, p ¼ 0.04). In the PROTECT group, 53% of subjects had a clinically meaningful reduction in depression severity (50% reduction on the MADRS) and 42% of PROTECT participants achieved remission of depression symptoms. In the referral group, 30% achieved a reduction in symptoms severity and 30% achieved remission. There was no difference in perceived stress. We work with victims to re-engage in activities that have been decreased as a result of being in a mistreatment situation. Victims often feel more empowered, have permission to reestablish prior activities that were enjoyable, and set limits with abusers. As the only standardized mental health intervention targeting the mental health needs of depressed victims of abuse, the PROTECT intervention has recently been extended for delivery throughout New York City. With funding from the New York City Department for the Aging and The Mayor’s Office to End Domestic and Gender-Based Violence (ENDGBV), we are now offering it to all victims with depression seen by community based agencies. In this, PROTECT is now being implemented throughout community-based agencies in New York City in an unprecedented move by the New York City Department for the Aging to provide financial support for PROTECT to all victims who need services. In the last 18 months, we have received over 150 referrals and been able to evaluate over 100 victims. The response reflects both the partnership and the tremendous mental health need. Since the impact of COVID-19 on New York City in mid-March 2020, we have had to move all service delivery to virtual modalities (video or telephone). Preliminary analyses of the follow-up data on depression severity suggest that the PROTECT intervention remains effective. Of patients who initiated treatment with a PHQ-9 score of 10 or above, 75% show a reduction of 5 points or more, with one third dropping 10 points or more on the PHQ-9.

Key Points • Elder abuse victims have a high rate of mental health needs, especially anxiety and depression. They are also vulnerable to effects of social isolation and loneliness often imposed by victimization. • Mental health status for both the perpetrator and the victim of elder abuse is integrally tied to abuse. More research is needed to understand the impact of trauma, life experience, and socioeconomic conditions on the needs of both parties. • There are opportunities to integrate mental health screening and interventions into elder abuse services to identify mental health needs among victims. Partnerships offer the chance to bring mental health and elder abuse experts together to improve the identification of mental health needs. Screening offers an unbiased way to identify needs.

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• Effective elder abuse interventions are part and parcel of fully identifying the underlying psychological and social dynamics and incorporating mental health treatment into the service plan. Interventions should be standardized and evidence-based to be extended to support a broader array of victims. • More interventions need to be developed and research support is essential to test what is helpful to reduce risk for victims. Future work can explore the possibility of targeting both the victim and the perpetrators.

Summary and Conclusions Elder abuse and mental health are intertwined. Victims and perpetrators both struggle with mental health issues that are viewed as affecting the victim-perpetrator relationship. In addition, the sequelae of abuse can precipitate mental health issues. Yet despite the overlap, it is only more recent research and abuse risk frameworks that highlight mental health and abuse interface. There has been very little opportunity for victims to address their abuse and mental health needs in an integrated manner. Finally, while there is a call for interventions by researchers who document the impact of mental health, as of this review, only a single mental health intervention targeting victims has been described, evaluated, and published in the literature. In addition, there are limited interventions that are able to work with alleged abusers. Future work should integrate evaluation of mental health needs of both victims and perpetrators into abuse services. While alleged abusers are often reluctant to accept care, victims frequently seek services for their perpetrators when they are receiving their own care. In sum, there remains more work to be done in this complex area.

Cross-References ▶ Intergenerational Transmission of Intimate Partner Violence: Summary and Current Research on Processes of Transmission ▶ Intimate Partner Violence and Intimate Partner Stalking ▶ Mothers’ Perspectives on Abuse by Adult Children ▶ The US Mental Health Care System’s Response to Intimate Partner Violence: A Call to Action

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Understanding Mothers with Dependent Adult Children: What the Literature Says . . . . . . . . . Intergenerational Relationships in Later Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mothering Difficult or Abusive Adult Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child to Adult Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Ideology of Intensive Mothering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Linked Lives of Mothers and Their Impaired Adult Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Empty Nest: Motherwork in Later Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Types of Adult Child Problems Reported by Older Mothers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Violating Maternal Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Feeling Disappointed and Disrespected . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Boundary Violations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ambivalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Whose Needs Take Precedence? Theirs or Mine? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I’m Afraid Harm Will Come to Her . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I Can’t Walk Away: I’m Attached . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If I Wait, He Will Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Internalizing the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Who’s to Blame? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health Impacts on the Mother . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Actions for Self-Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Frustration with Available Societal Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. J. R. Smith (*) School of Social Services, Fordham University, New York, NY, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_280

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Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Comply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

This chapter examines violence in the families of older adults by focusing on an understudied subject, older mother’s subjective experiences of being emotionally, physically, or financially abused by their adult child. A review of relevant literature from diverse fields including intergenerational ambivalence, child-toparent violence, and feminist studies on intensive mothering is included. The majority of the chapter focuses on the findings from original qualitative research conducted by Dr. Judith Smith with both low-income and middle-class/affluent older women (>60). The findings demonstrate how the indissoluble bond of mothers toward their adult children frames older women’s ambivalent feelings and actions and restricts their willingness to report or name the problem as “abuse.” The author suggests creating clinical interventions for women at risk for abuse by their adult children by framing the problem as structural (conflicts as a mother and the lack of available resources for troubled adults), rather than personal (or intrapsychic). Seeing the issue as a social problem rather than a personal failing as a mother could allow mothers to more honestly address the problem and make decisions with less self-blame about their own need for safety. Keywords

Elder abuse · Older mothers · Abusive adult children · Intergenerational ambivalence · Adolescent-to-parent abuse · Intensive mothering · Low-income and minority · Qualitative research · Motherwork

Introduction I know he needs to be out of here. He’s 36 years old this year. I’ll be 73. He needs – we need to be separated. I don't need all these on me at this age in my life. But I don’t want to see him, you know, have homeless or whatever because he won’t survive. He won’t survive. He will not survive. ...So that’s what I feel. You know, fears that there’s harm would come for him. I mean, that could come to me, too, but I just fear harm coming to him. Ms. Corrine

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Practitioners and researchers now explain the dynamics of elder abuse through the lens of the impaired perpetrator, rather than the lens of the stressed caregiver (O’Malley et al. 1984; Pillemer 1985; Pillemer and Finkelhor 1989; Penhale 1999). There is also agreement that the most likely perpetrator is a family member. The narrative above is by Ms. Millie, age 73, who, although she has Parkinson’s disease, is able to live independently and care for her adult son who has a psychiatric diagnosis. He went away for college, but after one year, he had his first psychiatric break and has been living in his mother’s apartment with her for over 15 years. She is “tired” of living with her argumentative, selfish, and at times threatening adult child, but refuses to put him out to fend for himself because she prioritizes her son’s safety over her own. In this chapter, elder abuse is examined using the lens of the impaired perpetrator, specifically examining how older mothers respond to and make sense of their experience of supporting their dependent and abusive adult children. By focusing on mothers, and not fathers, the author is not overlooking that men/fathers are also victims of abuse by their adult children. Instead, the focus on mothers is informed by the idea that parenting is in fact processed differently by women than by men. This perspective builds on the work of feminist sociologists and examines how societal mother-blaming and Western women’s aspirations to be a “good mother” shed light on the dilemmas of older women caring, once again, for their dependent adult children (Gary and Arendell 2001). Prevalence research on elder abuse has documented that a key risk factor for elder abuse is the dependence of the abuser upon the victim and living in the same household (Kosberg and Nahmiash 1996; Pillemer 1985; Pillemer et al. 2016). This focus on the abuser’s dependence, rather than the dependence of the victim on the caregiver is a change from early assumptions that guided the field (the strained caregiver). Forty years ago, O’Malley et al. (1984) conducted one of the first descriptive surveys on elder abuse attempting to document whether the phenomenon of “elder abuse” actually existed and to learn some of the characteristics of the abuser and the victims. They started with the hypothesis that the abused person (victim) is likely to be very old or physically or mentally disabled and dependent on the abuser for her/his care. The findings concluded that it was the impairment and dependence of the elderly person (victim) that created too much stress on the caregiver which explained the caregiver’s abusive behavior. Pillemer’s (1985) study provided the data to shift elder abuse understandings of risk factors to the abuser and his or her troubles and away from blaming the victim. There is no way to calculate precisely how many older women there are in the United States who, like Ms. Millie, are providing shelter for their adult children and struggle with the dilemma: whose needs take precedence – mine or my adult child’s? A recent report from the National Alliance for Gibson Hunt et al. (2016) estimated that at least 8.4 million Americans provide care to an adult with an emotional or mental health issue. Most were providing care for an adult son or daughter, many of whom were financially dependent on the family. Clearly not all persons with psychiatric problems are perpetrators of elder abuse or financially dependent on their families. The National Alliance of Caregivers reported that 63% of the adult

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children in their study were financially dependent on their families. Ms. Millie’s son was receiving Supplemental Security Income (SSI), which he used for most of his own expenses. He did not, however, contribute to the rent or reimburse his mother when he took her food. Ms. Millie, however, also did not describe herself to me as her son’s “caregiver.” She saw herself as providing a safe place for her son to live so that he could be safe and avoid living on the streets or in a homeless shelter. The Pew Research Center (2013) reports that the pattern of adult children moving back in with their parents has become more and more common in the United States and internationally. Katherine Newman (2012) names the growing pattern of families adapting to adult children’s return to the nest as “accordion families.” In her study of 300 families she reports that parents and adult children were able to make a relatively positive adaptation to what was often a temporary situation. The majority of adult children in her study had returned home to save money in order to complete college, graduate school, or to work and save until they could afford an apartment of their own. These adult children were usually cooperative, and glad to have the opportunity to reconnect with their families. In contrast, the dynamics in families where elder abuse occurs is not a situation of positive cooperation between the generations. This chapter presents findings from an exploratory research study that focused specifically on older women who were mothers of adult children who they experienced as “difficult.” “Difficult adult child” is a term Smith (2015) coined to describe mothers’ perceptions of the relationship with their adult child who had turned to them for on-going emotional, financial, or residential support. “Difficult” refers to the dilemmas the women expressed regarding how to handle their situation with their adult child that now included dependency, hostility, and lack of reciprocity. The research sheds light on the unique stressors that adult women/mothers experience when their impaired adult children return home or are once again dependent upon them. These findings present one of the first evidence-based reports on the subjective experience of victims of domestic elder abuse. Depending on the study and the country of origin, there are different findings regarding whether spouses or adult children are the more likely perpetrator (Pillemer et al. 2016). Some have suggested using the theory of codependency, which refers to abuse as a result of a strong mutual reliance between the victim and the perpetrator (Lachs and Pillemer 2015). Specifying how many instances of elder abuse within the family are caused by the spouse or the adult child is hard to measure. Many studies do not yet include questions that differentiate whether the family member perpetrator is the spouse or adult child. Pillemer and Finkelhor (1989) found that when all types of abuse were taken into consideration, the abuser was a spouse in 58% of situations, compared to the abuser being a child (or other individual) in 42% of the cases. When physical abuse alone was considered, 60% of situations were of spouse abuse (Pillemer and Finkelhor 1989). A serious barrier to understanding the dynamics of elder abuse is the unequivocal evidence that the vast majority of cases of elder abuse go unreported and undetected by formal service agencies (Berman and Lachs 2011; Burnes et al. 2016). Underreporting of elder abuse is one of the major barriers in this area of adult

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protection (Cohen et al. 2007; Killick and Taylor 2009). Roberto (2016) argues that many victims do not want to see their abuser, particularly when it is a family member, prosecuted. Filial norms and interdependent relationships between older victims and perpetrators often promote an apparent acceptance of the situation, which could explain a lack of reporting the situation to authorities or service providers. Whether women are more likely to be the victims of elder abuse is still being debated. Early studies suggested that the abused elders were more likely to be female (O’Malley 1984; Block and Sinnott 1980). Pillemer and Finkelhor’s study (1989) found males were the victims of abuse in 52% of the cases, women in 48%, roughly equally divided between males and female. Yet, when the severity of abuse was considered, risk for abuse was greater for women. Wolf and Pillemer (2000) found that seven out of eight victims were female (86%). Cottrell and Monk (2004) found that mothers and stepmothers were the most likely victims. Pillemer et al.’s (2016) prevalence study identified gender as only a “potential” risk factor for abuse in their global study. They cite studies in India, Portugal, Israel, and Mexico that have found that women are more likely than men to experience abuse, particularly emotional or financial abuse. This study focuses on older women who are mothers of dependent or “difficult” adult children. There is very little research that has been done on this topic. Despite the significant attention given to the early mother/child relationship in both popular and academic literature, the ways in which this relationship changes over time and specifically when adult children are in need of support from their families has seemingly been overlooked. There is a large and growing popular and academic literature on how adult children cope with and adjust to their older parents when they become frail or need additional support. In order to find literature to inform understanding the experience of older mothers at risk for abuse by their difficult or abusive adult children, findings from the literature on Intergenerational Ambivalence, Childto-Parent Violence, and feminist exploration of the Ideology of Intensive Mothering are presented.

Understanding Mothers with Dependent Adult Children: What the Literature Says Intergenerational Relationships in Later Life Very little has been written about the experience of older women and mothering a difficult or abusive adult child. There is no formal measure to capture when parenting ends (Smith 2012). Family ties in later life have been studied by looking at expectations of filial responsibility (Gans and Silverstein 2006), intergenerational solidarity and intergenerational conflict (Silverstein and Bengston 1997; Rossi and Rossi 1990) and most recently the intergenerational ambivalence model (Levitzki 2009; Luscher and Pillemer 1998; Peters et al. 2006; Pillemer and Suitor 1991; Pillemer and Suitor 2002; Pillemer and Luscher 2004; Pillemer and Suitor 2004).

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The intergenerational ambivalence model moves beyond a dualistic approach of characterizing family ties in old age as “good” or “bad” and provides a framework for studying all families, including those that include difficult or distant interpersonal relationships (Pillemer and Luscher 2004). This model also allows one to examine interactions between structural macro systems (race, gender, social welfare system) and the individual’s feelings of ambivalence (Connidis 2015). The intergenerational ambivalence lens allows for a complex study of issues that arise for older people as they respond to their adult children’s continuing, and, conflicting needs for support and independence. Parents experience ambivalence due to competing desires to launch their children into adulthood and to provide support to children in need (e.g., children with problems). Parents’ ambivalent feelings toward their adult children has been found to be associated with greater depression, lower quality of life, and poorer health among parents (Fingerman et al. 2008; Gilligan et al. 2015) In order to study ambivalent feelings among parents, most of the studies on intergenerational ambivalence use large-scale cross-sectional survey data that include a few questions to tap parents’ feelings of ambivalence assessed with Likert scale measures (Pillemer and Luscher 2004). Researchers using these large data sets are able to statistically discover significant relationships between the status of the adult child and the parents’ level of ambivalence. Marital status (not being married), low educational achievement, and mental health problems were found to significantly predict parents’ feelings of ambivalence (Pillemer and Suitor 2002). These findings support Hagestad’s (1986) work that posited that children who are “off time” in their transition to adulthood will impact their parents’ lives both directly and indirectly. Pillemer and Suitor (2002) have called for research on intergenerational ambivalence that can identify the contexts and specific factors which increase parents’ ambivalent feelings toward their adult children. They also noted the need for studies to focus on low-income and minority families, whose adult children, due to macro forces, are more likely to experience barriers to self-sufficiency.

Mothering Difficult or Abusive Adult Children A small group of researchers have examined how older parents cope with the demands of caregiving for an adult child with psychiatric problems who can also be abusive toward their older parents (Band-Winterstein 2015; Band-Winterstein and Avieli 2017; Band-Winterstein et al. 2014; Cohler et al. 1991; Cook et al. 1997). Avieli et al. (2015) examined older parents’ preparation for death among a group of caregivers whose adult children had been abusive toward them. They discovered that regardless of the parents’ efforts for planning their departure, they all were concerned about their children’s futures. Their “departure scripts” indicated that although they are preparing for the physical separation from their children, they have difficulty parting with their role as caretakers. Brownell and Heiser (2006) were the only researchers to study the effectiveness of an intervention program for older women who were victims of their adult children’s abusive behaviors.

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Child to Adult Violence The very idea of violence in the family, and specifically, violence by children toward their mothers, challenges idealized family life. Families are supposed to provide a safe harbor or a place of love and care. The reality of children abusing their parents was first identified by Harbin and Madden (1979) as “Battered Parents Syndrome.” There is now a sizable body of literature on adolescent-violence-to-parent abuse (AVPA). Holt and Redford define AVPA as “a pattern of behavior that uses verbal, financial, physical or emotional means to practice power and exert control over a parent” (2013, p. 1). Others name this social problem as “Parent Abuse” (Kennair and Mellor 2007). Commonly reported adolescent-to-parent abusive behaviors include name-calling, threats to harm self or others, attempts at humiliation, damage to property, theft, and physical violence. Parents of abusive adolescents experience emotional distress, physical and mental health concerns, work and financial difficulties, and problems in social and family relationships (Cottrell and Monk 2004; Holt and Retford 2013). Prevalence studies in community samples have identified between 6.5% and 10.8% of young people who have hit their parents at least once in the previous 1–3 years (Agnew and Huguley 1989; Peek et al. 1985). Holt’s (2016) review of the research shows that in terms of gender of the victim, a disproportionate number of mothers have been identified as victims of AVPA, at a ratio of approximately 8:2 (e.g., Evans and Warren-Sohlberg 1988; Ibabe and Jaureguizar 2010; Routt and Anderson 2011). There is debate about whether AVPA should be understood within the framework of “family conflicts” paradigm or the “gender-based violence” paradigm. Several recommend a gendered base conceptualization with a particular focus on how women are blamed for the behavior of their adolescents as a failure in parenting by family practitioners, judges, and social workers (Holt and Retford 2013; Hunter et al. 2010; Nixon 2012). Jackson and Mannix (2004) found that the mothers in their study assumed that they would be blamed for their adolescent’s behavior and this assumption often resulted in their not reporting the violence and remaining silent. The mothers they interviewed had internalized society’s idealized view of motherhood and did not want to face being seen as “bad” mothers if they reported the abuse. In addition, mothers wanted to protect their child despite their feeling poorly treated by their son or daughter. Adolescent to parent violence differs from adult children abusing their older parents in terms of the legal relationship between victim and instigator. Parents of adolescents have a legal responsibility toward their child. Victims of AVPA cannot “leave” the perpetrator in a way that might be possible in adult-instigated domestic violence contexts or elder abuse.

The Ideology of Intensive Mothering Most of the feminist analyses on how mothering impacts women’s sense of self have been conducted on mothers with very young children. These researchers have shown how the Western ideology of motherhood assumes that women’s and children’s

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interests should be exactly the same (Henderson et al. 2016). The ideology of motherhood assumes that mothers put their own needs far behind that of their children. Hays (1996) described that there were three key tenets to being a “good mother.” These three factors are part of what she called intensive mothering. First, “good” mothers need to make childcare their primary responsibility; second, their childcare should be child-centered; and finally, the children should be seen as priceless. Mothering ideology includes a perpetual set of tasks and activities for mothers, which Dillaway (2006) called “motherwork.” Finnish researcher and evolutionary biologist Rotkirch and Janhunen (2010) documented how mothers of young children report that their most prevalent feeling toward themselves and their mothering role is guilt. They defined maternal guilt as the woman’s internalization of her self-blame for not meeting her internalized goal to be a “good” mother. Caplan and Hall-McCorquodale (1985) documented how health professionals, the academic, and popular press often blame mothers, not fathers, for all the problems of their children. Very little has been written on how the ideology of mothering affects mothers of adult children (see Dillaway 2006, as exception). Pillemer and Suitor (1991, 2002) and Pillemer et al. (2007) studied parents of adult children, without an exclusive focus on the particular experience of women/mothers. Pillemer and Suitor have shown how parents’ feelings of ambivalence toward their adult children increase with the problems in the adult children’s lives. Their work highlights how the success of the adult child impacts the parent’s feelings about themselves and their adult children. Several qualitative researchers have done research that confirms intergenerational ambivalence as a salient theme in parent/ adult child and mother/adult child relationships (Levitzki 2009; Peters et al. 2006).

Linked Lives of Mothers and Their Impaired Adult Children The qualitative work by Smith, using constructivist grounded theory (Charmaz 2014) examined the situation of 29 older women over 60 years of age, who all self-identified as having “difficult” adult children, or adult children with mental health, substance abuse problems, or chronic unemployment. These problems had led to the adult children’s inability to maintain self-sufficiency and they had turned to their older mothers for renewed support. Her sample in the first wave purposely and only included poor and minority women (Smith 2015). Subsequent interviews were done with middle-class and affluent women (Table 1) and both demonstrated the linked lives (Elder 1994) of the adult children and their mothers. While all of the adult children had left the parental home in late adolescence or early adulthood, problems or transitions in the adult child’s life led to their need to return to their mothers for support. All of the women had willingly reopened their homes to provide shelter to their adult children for some period of time. Many of the adult children remained living with their mothers for many years, once they returned home.

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Table 1 Sample demographics Adult child’s Non-Poor Age age Barbara 62 32 Cynthia 69 31 Deborah 67 28 Doreen 70 50 Ellen 62 29 Lannie 63 34 Lenore 75 41 Lindsay 62 32 Lisbeth 76 45 Liz 66 32 Roslyn 68 33 Sharon 70 50 Wendy 66 42 N=13

Black/ Hispanic Education BA > BA > BA BA >BA > BA > BA BA > BA > BA > BA BA HS

Adult child’s Poor Age age Alana 64 34 Beverly 80 51 Carmen 66 24 Charlene 70 43 Corrine 72 35 Ella 70 49 Esther 63 34 Gaby 67 37 Juanita 65 42 Loretta 80 45 Lydia 66 49 Maria 66 45 Milagro 84 55 Millie 63 38 Sylvia 68 35 Vivian 67 49 N=16

Black/ Hispanic Education < BA < HS < BA < HS < BA < BA HS < HS < BA < BA HS HS < BA < HS BA HS

No Empty Nest: Motherwork in Later Life The women described different ways in which they provided resources for their adult children. All but one of the mothers had reported allowing her adult child to move back in with her when he or she needed a place to live. One woman and her husband, instead of letting their daughter live with them, paid for a separate apartment to keep her safe. In addition to shelter, many provided money and/or food. Twelve women were currently living with their adult child. Twenty-five had ever lived with their adult child. Other ways the women reported supporting their adult children was by helping with the grandchildren (many adult children moved in with their families), giving advice, supporting the adult child’s autonomous functioning, visiting the child in jail, and just “putting up with her.”

Types of Adult Child Problems Reported by Older Mothers Table 2 presents the types of problems that the women perceived their adult children experiencing. Most women reported more than one problem. Many of the problems were complex and would not be easily addressed. These included substances, aggressive behavior to others, aggressive behavior to the mother herself, and mental health issues. None of the women ever used the descriptor “elder abuse.” Some said “he was verbally abusive” or “he attacked me” when describing interactions between themselves and their adult child.

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Violating Maternal Expectations Super codes were discovered that described the process by which the adult children’s problems negatively affected the mother. They were labeled violating maternal expectations. Two types of broken maternal expectations were found. Mothers expected their children to treat them in a respectful manner, and the mothers also expected their adult children to live up to their potential as self-sufficient and independent adults.

Feeling Disappointed and Disrespected The adult child’s behaviors that disrupted the mother’s hopes and expectations for her child (and for herself as a mother) included lack of employment success and/or not persevering in school, not being reliable parents, smoking marijuana, and not being motivated to become productive. Several whose adult children had psychiatric problems were upset that the adult child did not seek or sustain psychiatric treatment and medication. Most had not given up on their child’s ability to change and expressed the hope that the child would “wake up” and things could change, no matter the child’s age or the length of the problem. Table 2 shows that almost twice as many poor women compared to non-poor women talked about how they felt disrespected by their adult children and three times as many poor women spoke about how they felt disappointed that their adult child had not achieved her/his full potential. Ms. Sylvia is 72 years old. Her two daughters have both returned to live with her, and her husband, in their small three-bedroom apartment. Each daughter has two young children. Side by side with feeling neglected by their seeming uncaring attitude toward her as she copes with Stage 4 cancer treatment, she also feels Table 2 Frequency of mother report of adult child problems, by poverty status No resources Substances Cleanliness Aggressive to others Aggressive to mom Poor parenting Interpersonal Mental Health Boundary crossing - stealing Boundary crossing – access to house Role violation – disrespectful or selfish Role violation – failure to achieve Total number

Poor 2 5 7 4 11 4 5 8 5 3 7 10 16

Non-Poor 1 4 2 1 4 1 3 8 4 2 4 3 13

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embarrassed and disappointed at the daughters’ impoverishment and lack of accomplishments. Both daughters had done some college, but never finished. Neither of them was employed. they have nothing, you know, they have no clothes, no houses, no apartment. . . they don't have anything. You know, they should have a car, you know, to drive their children around. I should have a car.

Ms. Charlene is 79 years old. Both of her adult sons (age 42 and 39) are living with her and refuse to help her financially. In describing to me his verbal abusive behavior toward her, she reported it in the context of his not having any respect for her. She wants him out, but he does not want to leave. If I talk to him, he tells me anything that comes to his mind. He doesn’t have any respect. He will curse and say nasty things. The only thing he has never done, he has never hit me. So, I don’t know if that will ever happen, but he yells at me and he’s very unpleasant. So, that’s my problem. And I can’t get him out. He will not leave.

Boundary Violations The second process variable that was discovered describes how the mother felt that her person or space had been invaded. Smith called this a boundary violation. These ranged from the adult child eating the mother’s food that she had cooked and saved for herself, disrespecting the mother’s need for quiet and cleanliness, to stealing from the mother, verbally insulting the mother, and physically attacking her. Many, but not all, of the boundary violations occurred within the context of the adult child coresiding with the mother.

Attempting to Take Over Mother’s Space Loretta owned a small home. When her son and his girlfriend had a child and no place to live, she let them stay in her small-enclosed front porch. They stayed for over 10 years and had many subsequent children. The parents and children took over all parts of the house without any regard for Loretta’s comfort or safety. Here she describes how the invasiveness included not letting her use her own bathroom when she needed to. The son attempted to involve the courts and falsely accused his mother of “stealing” the family home from him. He went as far as having Loretta arrested. Finally, after three years of help by an elder abuse attorney, Loretta was able to have her son and his children evicted from her home. When interviewed two years after the eviction, she reported feeling traumatized and still expecting to be surprised by another impingement by her son and his efforts to take away her home from her.

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Physically Attacking Mother Here Barbara reports an incident from several years back in which her son punched her and he was arrested. The story is told with the addendum that what she learned from his punching her is that “he has no love for me. . .he has no respect for me.” When interviewed several months later, he was once again living with her. She reported being scared that he would kill her, but, nevertheless, she wouldn’t evict him until she had a “safe place” for him to go. So, he holds off and punched me in my face. He hit me so hard I fell back with so many steps in my apartment. My eardrum was bleeding, my eye was bruised and my other neighbor, two doors down, rushed me to the emergency room. She made a police report, the police came and then that’s when they came and they locked him up. So, that tells me that my son has no love for me. My son has no respect for me because how can you take your hand and punch your mother like you’re punching some man in a boxing arena?

The most severe and constant attacks on her person were reported by Loretta. Loretta spent years without attempting to get outside help to stop her son’s attacks on her. The only way she finally got help was through a physician having her hospitalized and the ER sending her to an elder abuse shelter, where she continues to live in safety. She could not set any boundaries with her son. She will live her life in an elder abuse shelter, which is connected to a nursing home. Here, she finally has the peace and quiet that comes with being able to close her door and know that no one can invade her space.

Ambivalence A central issue related to protecting elders from abuse is understanding those factors that interfere with a person’s ability to take actions to keep themselves safe. The women’s stories about themselves and their difficult adult children were filled with vivid descriptions of their daily oscillating feelings about how much to help, when to prioritize their needs over their adult children’s and their fears about how others would see them if they took or did not take action to protect themselves. Analysis of the women’s stories illustrated that ambivalence for these older women with dependent or difficult adult children was an organizing principle of their daily lives. While research on parents’ responses to their adult children’s problems has revealed an increase in parents’ mixed feelings toward their adult children when the adult children have problems in their own lives, in this sample, while many reported both positive and negative feelings toward their adult child, they also were ambivalent about how to structure the relationship and their own lives in later life. The stories illustrate how the women are torn between trying to protect their adult child and being free of this responsibility which is negatively impacting their health and emotional well-being.

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Whose Needs Take Precedence? Theirs or Mine? Many of the women’s stories addressed their concern about the harm that they were inflicting on themselves by putting their adult children’s needs over their own. While Beverly states that although she wants to protect herself, at the same time, she will not give up on them (her daughter and grandson). The opening quote in this chapter (p. 1) by Ms. Corrine states the same mixed feelings that are part of her daily life. “You know, fears that there's harm would come for him. I mean, that could come to me, too, but I just fear harm coming to him.” Of course. ..I’m not going to do anything that’s going to put myself in jeopardy, pushing myself too far, because I know I can’t. My heart is – I get palpitations and I get stress. So, I have to step back a step. But I can’t give up on them. I’m still trying to help them. But at the same time, I can’t keep on leaving myself out. I have to help myself. And I’m at a crossroads here. Beverly

Esther’s son moved back in with her when he and his girlfriend separated. He is unemployed, depressed, and smoking a lot of marijuana. Listening to Esther, her story expressed her feeling of the weight of time moving on and her standing still. Approaching 65, she was ready to retire and return to her home country. Yet, she feels compelled to wait until her son gets the resources to become self-sufficient, in this case his green card. So, I want to go back home now. That’s my biggest problem and he’s not doing anything. I want to go back to my country. And he’s not doing anything, not working. It’s just delaying me from going home. Because I don’t want to leave him, you know, not having a woman and not working, nothing. So, I hope he gets documented, he’d be able to get something to do and I could go home. Esther

Lindsay was in the middle of a divorce, getting ready to sell her house and try a new life outside of the United States, when her daughter had a series of psychotic episodes. She was hospitalized five times in the previous 6 months. Lindsay had to take out an order of protection excluding her daughter from staying at her place, after she had set a fire and physically attacked her and her siblings. On the one hand, Lindsay feels empowered by feminist writers who warn against women losing themselves in their role as mother; yet she cannot sleep at night, and cannot see how she can move on when her daughter is in danger living on the street. I don’t know where we go from here. I just want her better. But I’m probably asking – I’m also aware that she may not get better. . . .

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J. R. Smith Maya Angelou, as a matter of fact, wrote "women have to stop defining themselves as in the role is the mother". . . But it’s a very, very difficult line to walk between – I try very hard to take my emotions out of it, but, you know, you’re a mom. How do you do that? You know. I know that her being with me is enabling, but to go to bed at night and say, “my daughter is on the streets, sleeping in a park”, okay, and god knows what could happen to her, you know, it takes a lot tougher person than I am to do that, you know? Lindsay

I’m Afraid Harm Will Come to Her Lisbeth described herself as being like a “mule on a harness.” The harness is her need to protect her daughter. Despite the 20 plus years of bailing her daughter out of one mess after another, she could not turn her back on attempting to keep her child safe. As she tells me about her priority to her daughter’s safety (she has to have a place to live, she has to eat), she inserts this decision criteria as a part of a continuing dialogue she has with her friends and husband, who most likely are questioning her way of living. She compares herself to her husband who she sees as “not bleeding inside” the way she does from the stress. She feels alone in her actions and feelings. I could remember telling – being so upset and telling my friends – “But she had to have – she had to have a place to live. She had to eat.” But I think it’s very hard as a mother to – I mean, my husband was always lucky in that it never pierced his – he didn’t bleed inside the way I did. Lisbeth

I Can’t Walk Away: I’m Attached Barbara calls her willingness to tolerate the status quo, despite believing she might be killed, as “love.” He has to be put out and I don’t know if I have the strength to do it. I don’t feel I have the strength to do it because I love him too much. But he's got to go because I'm going to die there. And he's going to hurt me there. He's going to kill me there. Barbara

If I Wait, He Will Change Loretta kept closing her eyes to the numerous ways she felt unsafe and invaded by her son and his family’s presence in her small house. She reflected that what allowed

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herself to let them stay all the past 15 years was her belief that things would change. Either her son would move out voluntarily when they had “the next” child; or he would return from looking for a job and report success and be able to go. Yes, because I used to say to myself, “When he has the next. . .” I would tell my friends, “The next one he’s going to find a place,” but each time, I had a little sympathy. I said – try and help him out because I think – every time he goes away, I think he’s going to do good.

The mother’s mixed feelings also appeared in stories about calling the police or going to court in order to protect herself from the adult child’s attacks. But once faced with the choice of having the child actually arrested, many recanted and as Juanita said, “How can I put her in jail. . .that’s my daughter.”

Internalizing the Problem Who’s to Blame? Self-blame was heard in nearly every woman’s story. Several feared that their children’s problems were caused because when they were small the mother had to work, or use babysitters, or missed out on having had a man in the house, due to divorce or death. Some acknowledged that they had been emotionally absent when their children were young, others believed that they had “spoiled” their child and made their lives too easy. There wasn’t a father around too much. I don’t know if that makes the difference. I don’t know if that would have helped if they had a father around, I actually think that in his twisted mind, my youngest son, not seeing a father around bringing in what they call the bread and butter, he thinks it’s my duty because I was the only one he saw. He thinks it’s still a woman’s job to take care of him.

But you see, in my situation I go around with the guilt that I did not do enough, I did not do the right – not enough. I did not do the right things to really put them on the road for a better life. Charlene

I think I know where I went wrong because I tried to make it easier for her. Alana

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I said there’s something I missed or something I did, but I don’t know what it is. Maybe I didn’t pay enough attention. I think that’s what it might be because I always had to work. He always had to go to daycare. I mean, I used to take him on vacation every year. And when we used to go we used to go to the beach a lot. But I just feel that maybe I didn’t do enough. – I worked. Greta

Health Impacts on the Mother In addition to self-blame and guilt, many described feelings of depression and awareness of the long-term impact the stress had had on their health and mental health. Many reported being “tired” of focusing on their adult child and not themselves. Lisbeth was approaching her 80th birthday. She described an increasing awareness of mortality (running out of gas) and her wish to live a different type of life. Because I think it has really done a number on my health in the sense that I have bad irritable bowel syndrome. And I’ve had ulcers, and I think that – And, plus, I would say that I’ve run out of gas. I just don’t have the emotional reserves to tap into. I just don’t. Lisbeth

Actions for Self-Protection Table 3 describes the types of actions that the mothers reported that they took to alter their situation. Half of the women who had experienced some type of abuse (physical, verbal, financial, or emotional) had taken the initiative to report the problem, either by calling the police or going to family or housing court. Yet, two of the women who had had their adult children evicted or excluded from their homes by court order had reopened their homes to the adult child who was again living in their homes. Some who did not repent on the order of exclusion forbidding the adult child from reentering the house still felt remorse and questioned whether they had done the right thing. Lucille’s son and family had been out of the house for over two years, but she still bears the scars of the years of threats and often fears that the harassment will begin all over again. Setting limits seemed easiest for Betty with her son, Ronald. On the one hand, when she learned that he was having marital problems, she and her husband opened their home to him and his four-year-old son. As soon as she then learned that he was using drugs, she said he could stay in the house only if he immediately enrolled in drug treatment. One year later, after having driven him every day to a methadone clinic for treatment, and then being with him through a detox from the methadone, she discovered that he was continuing to shoot heroin, she immediately acted. She

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Table 3 Actions taken by mother for protection

Poor

Vivian

Abused Physical (XX) Stealing from mom (X) Sexual (S) Legal acts Current against Mom used coMother set mother (L) legal system residence boundaries L Order of protection Order of exclusion Police X Took away keys to house XX Police, ER Order of protection Changed locks XX Police Family court X, S

Lydia Durene

X XX

Name Loretta

Esther Milagro

Juanita

Police Police, ER Evicted

Charlene Non-poor Hope X Barbara

XX

Liz Lisbeth

X X

Mother living in elder abuse shelter Imprisoned

X X

PINS Police Police, ER

Set boundaries using the law Legally evicted

Reverse mortgage You can’t live with me

X

Imprisoned Evicted Can’t attend family dinners unless taking medication

took a photograph of the syringe she discovered in her home to make the problem real to herself, and told him he had to leave the house. When we spoke, Ronald was living on the streets in the small rural town where she lived. He was selling drugs. All her friends and neighbors knew him and saw him homeless on the streets. Betty would only let Ronald into the house for short visits. If he stole from her, she took

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him to court. She is hoping that he will eventually “wake up” and get himself into treatment. She ended our interview talking about how hard it is to do “tough love” and “let go.” She hopes that her son will wake up and come around to choosing a different life. Tough love, sometimes, doesn’t feel like love. It just feels like – exasperation, pure hatred. But you have to do it for yourselves. More than for the child, I guess, it’s such a balance in there. And one’s person’s answer is not another person’s answer. That’s what I’ve learned, everybody walks their own path. We all do. That’s my parting thought. Betty

Frustration with Available Societal Interventions Several of the women expressed frustration that the only route that they perceived that was available to help them with their adult child was legal means (jail, court orders). Like Barbara who continued to live with her abusive son, others expressed that while they wanted their adult child to be removed from their care, they would only accept the removal if they could be assured that the adult child would be placed in a safe alternative living space. Sending the child to prison or to live on the streets was not seen as safe alternative. Others expressed frustration with what they saw as a broken mental health system. Lisbeth has been the safety-net for her daughter with mental illness for 21 years. After numerous hospitalizations that lasted only a few days, she believed that the only answer for her daughter is court-ordered psychiatric medication. Yet, the state she lives in prioritizes patients’ rights for self-determination over mandated psychiatric medication treatment, and her daughter consistently refuses treatment. Lisbeth is frustrated and continued to be the “mule on the harness” – bailing her daughter out when each new crisis occurred.

Conclusion This chapter looks at elder abuse through the lens of older mothers – women over 60. This qualitative data sheds light on one aspect of domestic abuse – when the perpetrator is the impaired adult child and the mother is (relatively) cognitively and physically healthy. All the adult children in the sample had had some period of independent living away from their families prior to their return to their mothers for support. Substance abuse, psychiatric illness, and prolonged unemployment interfered with the adult child’s pathway toward independence. All but 2 of the 29 women interviewed in Smith’s sample allowed their children to move back in with them. Co-residence is a well-known risk factor for elder abuse, particularly when the abuser is dependent upon the victim.

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The study builds on Luescher and Pillemer’s theory of intergenerational ambivalence (Luescher and Pillemer 1998) and demonstrates the centrality of ambivalence when working with women who are being abused by their adult children. The mothers feel torn between their desire to protect their child and their wish to protect themselves. They feel torn between wanting to have their adult child “launched” and back in the world as an independent person and their fear that the adult child cannot make it on their own. They also have mixed feelings toward their own children – feeling love and hate. None of the women, when describing the abusive behavior of their adult children, labeled themselves as victims of elder abuse. Instead, they told stories of their dilemmas as a mother and the confusion they experienced when their adult child treated them in a way that violated their expectations of how a child should treat their mother. The mothers did not want to be treated with disrespect (verbal and emotional abuse) or be physically hurt (physical abuse) but were also conflicted when it came to removing their adult child from their home or calling the police within the context of what they saw as their maternal role to protect their adult child. Researchers in the field of domestic violence with older and young women have created various models to conceptualize the barriers that can interfere with women leaving abusive relationships. Barriers to help-seeking for elder abuse and domestic violence have been described as occurring on the micro, mezzo, and macro levels (Beaulaurier et al. 2007; Grigsby and Hartman 1997; Schiamberg and Gans 1997). This research contributes to the literature on barriers to help-seeking for victims of elder abuse: women’s commitment to the maternal role is both a micro and a macro barrier. On a micro level, the women’s stories demonstrate that they are struggling with their own personal guilt, self-blame, and mixed feelings toward their adult child and their own conception of themselves as good mothers. On a macro level, the women perceive that they are the sole safety net for their adult children. A reason given by many for not evicting their abusive adult child is their inability to live with the fear and uncertainty that they would feel if their adult child had to fend for themselves on the streets. Some readers may label these fears as “enabling” or “infantilizing.” Others might say that this is a realistic fear given the absence of supports for vulnerable adults in our society with psychiatric, substance abuse, or chronic unemployment. Some of the women reported that they could not evict their child because others would see them as “heartless” or “selfish.” The macro ideology of “the good mother” acts as a barrier against self-preservation for some. The elder abuse field can learn from researchers studying Adolescent to Parent Violence. Holt has named violence directed to a parent by an adolescent a “double stigma” (Holt and Retford 2013, p. 5). The women are forced to face charges of having a problematic child, and, the experience of being abused in their home. In addition, institutional policies leave parents with abusive adolescent children in a “no win” position (Clarke et al. 2017). The parents also do not have the language to name their problem with their adolescent children (Clarke et al. 2017). What would elder abuse service delivery look like if professionals assumed a matricentric lens? A program for elder abuse victims at the Legal Education Associated Program of the Jewish Association for Services for the Aged (JASA/LEAP) offers some promising ideas. They offer a support group for victims of abuse, which

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the social workers believe is an excellent way to help women gradually consider interventions to protect themselves from their adult children and grandchildren. The groups are primarily women – mothers and grandmothers. The members of the group are at different levels of contemplating change regarding their abusive situations. They discover that they are not the only ones who are being threatened or mistreated by their adult children. With time, they are able to see the problem solving of other group members who ultimately decide to take out a court order of protection or evict their adult child. They can see that this woman who chooses to protect herself is not a “bad mother” but instead is someone who is empowering herself toward self-care. JASA/LEAP also offers the women on-going individual counseling along with being in the support groups. These social workers shared in a focus group facilitated by Smith how frustrating it can be to work with mothers who are being abused by their adult children. They reported that they have learned to not use the word abuse when forming a relationship with a family member who has been attacked by another family member. Instead they talk about the problematic behaviors of the adult child or the spouse. The staff have learned that it may take many incidents and setbacks before a mother is ready to take action to remove her adult child from the home. While frustrated, they are cognizant that these clients are adults and have the right to self-determination. They do report that if they are able to encourage the women victims to join the elder abuse support group, change is much more likely. Victim support groups for elder abuse are not yet an integral part of many programs servicing this population. Instead, older women are often referred to local mental health agencies for counseling. Referrals are also given to ACT teams that can address the crisis situations in the family with the adult child. Another avenue for referrals can be Al-Anon groups for parents of adult children with substance abuse and mental health issues where mothers can share their individual story and be supported as they struggle with the difficult decisions regarding selfcare. National Alliance for Mental Illness also offers groups for parents of adult children with mental health problems. Social workers and psychologists who offer supportive counseling can gradually help victims of elder abuse understand and resolve the conflicts that interfere with self-care. ▶ Chapter 194, “Intersectionality of Elder Abuse and Mental Health Issues: Needs and Interventions for Victims” in this volume by Sirey, Minor, and Berman addresses the importance of understanding how the underlying depression of the victim needs to be addressed as one is helping her protect herself. In addition, the mother’s own traumatic history can interfere with her ability to prioritize her own well-being over another’s. Researchers in the field of elder abuse can improve the situation of elder victims who are mothers of adult children by helping to create data collection measures that identify the gender of the victim and the relationship between the victim and the perpetrator (adult child or spouse). Currently, the prevalence of mothers living with their difficult adult children is unknown. This study supports several possible policy directions that could help mothers who are victims of their adult children’s violent behaviors. An obvious one is significant increase in affordable housing for vulnerable adults who are living on SSI or other government benefits. A second is

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expansion of funding for community mental health and substance abuse treatment centers. A third is the beginning of a public dialogue about the unnamed problem of older mothers as the default safety net for their adult children who have serious mental health and substance abuse issues. Feminist gerontologists and elder abuse advocates need to help mothers and the elder abuse providers acknowledge the need to address the unique situation of older women who feel they have no “choice” regarding providing care and safety for their adult children. Women are depended upon to provide unpaid care for frail and dependent family members. Feminist gerontologists have noted that becoming a family caregiver is not a “choice” when there are no viable societal alternatives (Funk and Kobayashi 2009; Hooyman and Gonyea 1995).

Key Points • The research sheds light on the unique stressors that older adult women/mothers can experience when their impaired adult children turn to them to provide residential and financial support. Co-residence is a well-known risk factor for elder abuse, particularly when the abuser is dependent upon the victim. • “Difficult adult child” is a term Smith coined to describe mothers’ perceptions of the relationship with their adult child who had turned to them for on-going emotional, financial, or residential support. “Difficult” refers to the dilemmas the women expressed regarding how to handle their situation with their adult child that now included dependency, hostility, and lack of reciprocity. • Older mothers who open their homes to their “difficult adult children” report experiencing boundary violations, including the adult child eating the mother’s food that she had cooked and saved for herself, disrespecting the mother’s need for quiet and cleanliness, to stealing from the mother, verbally insulting the mother, and physically attacking her. Many, but not all, of the boundary violations occurred within the context of the adult child co-residing with the mother. • Older mothers (>60), despite their advanced ages, continue to be affected by the internalized mandate to be a “good mother” and believe they must prioritize their adult children’s needs over their own, even when their own health and safety are at risk. • The research suggests the utility of a gendered lens on elder abuse by adult children, as the mothers’ internalized self-blame for their adult children’s problems interferes with their ability to get help for themselves when in danger. • Older mothers experience shame and disappointment when their adult children are not able to succeed in work and relationships, and when they treat their own mothers with disrespect and a lack of reciprocity. • Ambivalence was expressed by all the older mothers (poor and nonpoor; minority and white) regarding their situation with their “difficult adult children.” Side by side with feeling obligated to continue to protect their adult children, the mothers were “tired” and wanted to be free of their adult children’s aggressive, selfish behaviors, as well as wanting to focus, instead, on their own needs in later life.

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• Social workers attempting to help older women/mothers protect themselves from their abusive adult children confirm that mothers’ wishes to protect their adult children and their fear of being blamed by professionals for their adult children’s problems can be obstacles to providing effective services.

Comply The research presented in this chapter is one of the first to use qualitative methods to examine how older mothers make sense of their adult children’s delayed pathways to self-sufficiency and the conflictual mother/adult child relationship that can ensue, especially when the two are living together. The aim is to help practitioners understand what it is like to live with a dependent adult child who is “off-time” in their adult development and treating his or her mother with disrespect and at times abusive behavior. A mother’s resistance to taking help to protect herself from elder abuse services can be confusing to practitioners. Helping professionals need to advocate for structural solutions to care for dependent or idle adults, as well as improved mental health services to support elder abuse victims and their adult children. Kennair and Mellor (2007) have suggested naming adolescent to parent abuse “parent abuse” because they believe that until it is named, it will continue to be hidden, and families will struggle in isolation with what is a social problem. Could the field of elder abuse consider a new name for older mothers’ abuse by their adult children to place it within the gendered maternal context?

Cross-References ▶ Addressing Intimate Partner Violence Within the Healthcare System ▶ Barriers to Leaving an Abusive Relationship ▶ Caregiving and Elder Abuse: A Complex Relationship ▶ Intersectionality of Elder Abuse and Mental Health Issues: Needs and Interventions for Victims ▶ Intimate Partner Violence and Intimate Partner Stalking ▶ Perpetrators of Elder Abuse

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Intersectionality of Race, Ethnicity, and Culture in Neglect, Abuse, and Violence Against Older Persons: Human Rights, Global Health, and Systems Approaches in Pandemics Mary Beth Quaranta Morrissey, Patricia Brownell, and Thomas Caprio

In Memory of Toshio Tatara This chapter is dedicated to the memory of Toshio Tatara, elder abuse expert and pioneer in scholarship on diversity in elder abuse research and policy in the United States and internationally. His accomplishments are numerous (Stein 2012), but his vision for expanding the field of elder abuse research, policy, and practice to address an acknowledged gap in understanding its cultural and race/ethnicity dimensions is especially relevant here. In 1997, Dr. Tatara served as guest editor for the first issue of the Journal of Elder Abuse & Neglect dedicated to scholarship on race/ethnicity in elder abuse (Tatara 1997). For his edited book, Understanding Elder Abuse in Minority Populations, he brought together experts who examined elder abuse in several minority populations: Black, Hispanic, Asian American, and American Indian (Tatara 1999). While not the first to examine elder abuse and culture, Dr. Tatara framed this as an

This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. M. B. Q. Morrissey (*) Global Health Care Innovation Management Center, Fordham University, New York, NY, USA Global Healthcare Innovation Management Center, Fordham University Gabelli School of Business, West Harrison, NY, USA e-mail: [email protected] P. Brownell Graduate School of Social Service, Fordham University, New York, NY, USA e-mail: [email protected] T. Caprio Finger Lakes Geriatric Education Center, University of Rochester Medical Center, Rochester, NY, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_337

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M. B. Q. Morrissey et al. important area of inquiry. As a founding member of the International Network for the Prevention of Elder Abuse (INPEA), he was a leader in the development of significant research on international issues in elder abuse as well (Personal Communication, Susan B. Somers, President, INPEA, May 15, 2020).

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . COVID-19 and Older People: Heightened Risks in the Pandemic Environment . . . . . . . . . . . . . Human Rights and Public and Global Health Frameworks: The Right to Health, Palliative Care and Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . An Intersectional Lens on Elder Abuse: Historic Inequities in Social and Economic Determinants of Health and Health Disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Elder Mistreatment and Black/African Americans: Research Findings . . . . . . . . . . . . . . . . . . . . . . . Mistreatment and Latinx Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mistreatment of American Indian Elders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Elder Mistreatment of Asian-American Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Palliative Care as Public Health Policy Response and Intervention: Mitigation of Older Adult Risk and Suffering in Pandemics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . International Palliative Care Frameworks: The Public Health Strategy . . . . . . . . . . . . . . . . . . . . . . . Universal Instrument to Promote Human Rights of Older People (Convention) . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Although prevalent in the 1990s, research on social and economic determinants of elder abuse, including race, ethnicity, and culture, has lagged in recent years, compromising understanding of elder abuse as a public health problem calling for systems responses. The COVID-19 pandemic has highlighted the tragic impact of substantial disruptions in access to care across fragmented health systems and community-based settings on vulnerable older adults and, in such crisis conditions, the persistence of both violations of older adults’ human rights and historical inequities in their treatment. Older adults have been disproportionately affected by COVID-19, particularly older Black/African Americans and Latinx and those living in congregate settings such as nursing homes, assisted living facilities, and prisons, as reflected in reporting of cases, hospitalizations, and deaths. American Indian reservations and indigenous and tribal communities are also struggling with the effects of the pandemic on the health and economic security of their members. The pandemic is exposing challenges that have heretofore been ignored or covered up, or have remained otherwise invisible, such as institutional neglect, poverty, deprivation, and isolation, yet have deepened suffering of older adults. However, little is yet known about older persons’ experience of abuse, neglect, and violence during pandemic crisis conditions, such as sheltering-in-place, quarantines or lockdowns, or situations of scarce resources including intensive care unit beds, medical equipment, and personal protective equipment. The risks created by these conditions and their palpable

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urgency call for critical examination of the contribution of structural inequities to older adults’ heightened risk in disaster and post-disaster environments and the disproportionate impact of crisis conditions (Institute of Medicine [IOM], Crisis standards of care: A systems framework for catastrophic disaster response: Volume 1: Introduction and CSC framework. The National Academies Press, Washington, DC, 2012. https://doi.org/10.17226/13351) upon the human rights of diverse older adult populations and communities. Keywords

COVID-19 · Culture · Neglect · Elder abuse · Social and economic determinants · Human rights · Global health · Public health strategy · Palliative care

Introduction Since the 1990s, elder abuse research among diverse communities, such as Black/ African Americans, American Indians, Latinx, Asians, and others, has lagged. The present COVID-19 pandemic highlights the tragic results of fragmentation in care across communities and health systems and historical structural inequities in our society, including forms of violence, systemic discrimination, and racism embedded in social structures. Older adults and older communities of color have been disproportionately affected by COVID-19, particularly those who are living in congregate settings such as nursing homes, adult care facilities, assisted living communities, prisons, and places of detention. The face of the older adult afflicted with severe COVID-19 illness, dying alone in a sterile hospital room or congregate care facility with no loved ones to offer comfort and care; isolated at home, or homeless and hungry; or struggling to survive as an essential worker in a low-income job, must not be forgotten. The long-standing older adult humanitarian crisis, elevated to heightened attention by COVID-19, serves as a clarion call for more robust public health policy responses and promising interventions and practices that will mitigate older adult suffering and risks of violence, neglect, and abuse both during the pandemic and in post-pandemic periods of recovery and resilience. This chapter will examine the social and economic determinants of older adult health, and death, and the confluence of human rights violations and crisis conditions that have contributed to the older adult humanitarian crisis at the cusp of this third decade of the twenty-first century. Public health strategies integrating systems approaches that respond effectively to the urgency of the crisis and relieve older adult suffering will also be discussed.

COVID-19 and Older People: Heightened Risks in the Pandemic Environment The confluence of long-standing human rights violations experienced by older adults and the crisis conditions created by the COVID-19 pandemic has sparked widespread fear and panic and heightened risk and suffering burden (Morrissey 2011, 2015) for older people around the world. While COVID-19 has affected all age

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groups, globally, those over 80 years of age are five times more likely to die than others in younger age cohorts (World Health Organization, [WHO] 2020), and in the United States, older adults and, in particular, nursing home residents are bearing the brunt of the pandemic as measured by case and mortality data (Cantor et al. 2020; CMS 2020; New York State Department of Health [New York] 2020; New York City Department of Health [New York City] 2020). Social and economic determinants of health, and death (Weil 2020), for all populations, but especially for older adults of diverse backgrounds, have been foregrounded during the pandemic. Drawing on the public health perspective that effects a shift in focus from individual health to community or population health (Gostin 2014; Hodge 2018; New York State Bar Association Health Law Section [NYSBAHLS] 2020), there is a broad and expanding range of social and economic factors that influence health outcomes for older adults. This is especially true in crisis conditions of scarcity, including poverty, race/ethnicity, culture, sex, age, primary language, sexual orientation, disability status, gender identity, employment, education, vulnerability, and underlying chronic medical conditions (Pillemer et al. 2020; WHO 2020; New York 2020; New York City 2020). Global health law scholar Lawrence Gostin (2014) explains that these determinants are for the most part located outside the health sector and thus cannot be subsumed under the right to health and guaranteed health goods and services. Not only is it the case that each of these factors individually affects older adult health outcomes, but collectively, the way in which they intersect and interact may also have an impact upon older adult population health. Understanding these patterns of intersectionality may also help to illuminate the complexity and burden of cumulative disadvantage on older adults’ health and health outcomes during the pandemic. More specifically, older adults have been disproportionately affected by the current pandemic in terms of disease burden, experiencing the majority of severe illnesses associated with COVID-19 (NYSBAHLS 2020; CMS 2020; WHO 2020; New York 2020; New York City 2020). Globally, an estimated 66% of people age 70 and older have at least one underlying health condition, which places them at greater risk of severe COVID-19 illness (United Nations 2020). A constellation of social and health problems for older adults existing before the pandemic, including underlying conditions, social isolation, limited access to health care and transportation, lack of mobility, poverty, and food insecurity, have been exacerbated by COVID-19 crisis conditions. Age discrimination in decisions about allocation of scarce resources has further limited older adults’ access to medical care and potentially life-sustaining interventions (NYSBAHLS 2020). In rural areas, poor communities, congregate living facilities, prisons and homeless shelters, lack of adequate health-care services and transport, crowded living conditions, and uncertain sanitary conditions have hastened the spread of COVID-19, with particularly devastating consequences for older adults. The pandemic has drawn heightened attention to inequities across race, ethnicity, gender and class, and the social and economic determinants of health, and death (Weil 2020), with important implications for understanding elder abuse. According to Han and Mosqueda (2020), there has been a significant increase in older adult abuse reports during the pandemic, ranging from financial scams to family and social

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and political violence, and further, they report that the Federal Trade Commission (2020) has issued public warnings alerting the public to this development. Similarly, on the global stage, the United Nations reports a rise in abuse and violence, especially against older women: . . .Abuse of older persons has been on the rise and estimates before the COVID-19 pandemic suggested that 1 in 6 older persons were subjected to abuse in 2017. Since the outbreak of COVID-19, there have been widespread reports of increased rates of violence against women, and particularly intimate partner violence, exacerbated by lockdown conditions. While agedisaggregated data is not available, policy responses need to incorporate the needs and rights of older persons, especially older women, whose dependence on family members for their daily survival and care make them especially vulnerable to abuse. Measures to restrict movement may trigger greater incidence of violence against older persons and all types of abuse physical, emotional, financial, and sexual, as well as neglect. The pandemic leaves many older victims without access to assistance and services. (2020, p. 7)

Study of the pandemic yields knowledge that challenges theories and paradigms of aging that promote paradigms of successful aging and, in turn, elder abuse as a function of individual failure to age successfully, rather than failure of the social structures and systems themselves (Morrissey et al. 2019b). In the case of COVID-19, the pandemic has become a crucible of suffering for older adults (NYSBAHLS 2020). An ecological systems perspective helps to inform understanding of the needs and lived experience of older adult populations in the contexts of history, violence, systemic racism, and civil unrest as they have unfolded during the pandemic and, in turn, guides the design of public policies and promising interventions and practices that will address needs across diverse older populations and assure a better future for all older adults. The pandemic provides a fertile opportunity for a focused case study of elder abuse risk and suffering during disaster and public health emergency crisis conditions. Not only have pre-existing vulnerabilities faced by underserved and marginalized populations during the COVID-19 pandemic been magnified during pandemic crisis conditions, but in some cases older adults’ vulnerabilities to risk have been compounded in the multiple systems contexts of the pandemic, including policy and policy implementation system failures that have occurred in response to the pandemic (Ahmad et al. 2020). For example, older people may have faced heightened vulnerability to abuse and neglect as the result of shelter-at-home policies. Government failures to provide adequate support to nursing homes may have also increased risks of abuse and neglect. Those older people locked down or sheltering in place with abusive family members or caregivers, or abandoned in nursing homes because of inadequate staffing and resource allocation such as PPE, and underfunding, may have faced increased risk of abuse and neglect, and such risks may have been intensified by lack of contact with service providers, faith community members, and neighbors (AGE Platform Europe 2020). Older people, especially women, are among the caregivers for ill family members and others in institutional settings, placing them at risk of infection as well. Older women age 80 years and above are more than twice as likely as older men to live alone and more likely to be adversely affected by isolation and sheltering-in-place (WHO 2015).

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During the COVID-19 pandemic, income and employment have been affected, with the rate of older adults in the labor force worldwide already declining (International Labor Organization 2018). Income and food insecurity can increase suffering of older people during the COVID-19 pandemic. Older people living alone who have not been digitally connected remain isolated from both family and friends, as well as from communications critical to ensuring safety and protection from infection (Seifert 2020). The increased risk of social isolation can be detrimental to their health and well-being (Swinford et al. 2020). Short- and long-term policy interventions must include a commitment to human rights – health, dignity, safety, and inclusiveness (United Nations 1991). Health care is a human right, and every human life has value regardless of age. Physical distancing can be life-saving during a pandemic, such as COVID-19, but must be tempered by strengthened social supports and services for older adults. COVID-19 calls for the full integration of older people into a socioeconomic and humanitarian response plan, “strengthening the national and international legal framework to protect the human rights of older persons” (United Nations 2020, p. 4) – critical to societal well-being now and in the future. The knowledge and lived experiences of socially marginalized groups have a vital role in the pandemic response and more generally, shaping progress in addressing health disparities and inequities and eliminating systemic racism and discrimination (Ahmad et al. 2020). Ensuring that older people are full participants in policy planning is essential to ensuring dignity, safety, and well-being (United Nations 2020). Older adults who are members of racial and ethnic minority communities with socioeconomic, language, and health barriers may feel doubly oppressed, facing agism, social exclusion, and underlying health conditions, coupled with lack of familiar supports such as senior centers, faith communities, friends, and family members who may be isolating themselves as protection from infection. Elder abuse research has been criticized for lack of attention to diverse subjects and communities and to the lived realities of older people. Race and culture also mediate lived experience of abuse in older age (Walsh et al. 2010), and while they can be protective factors, in pandemic conditions of isolation that pose a risk to safety, societal attitudes toward race and ethnicity can serve to further marginalize already oppressed older persons. Learning more about the intersectionality of race/ethnicity, culture, and elder abuse can be a first step in empowering older adults from diverse communities to make their voices heard.

Human Rights and Public and Global Health Frameworks: The Right to Health, Palliative Care and Pain Relief The nexus of health and human rights and their reciprocal and interdependent character within the larger human rights paradigm has been recognized as early as the 1990s (Gostin 2014; Mann et al. 1994). It is well established that the realization of health and human rights is a progressive project that is not yet a historic achievement and that regressive policies may yet impede the realization of health

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and human rights, even during pandemics. For example, health itself as a human right may support and reinforce other human rights, such as rights to water, sanitation, food, housing, education, and transportation. However, burdens on the right to health through regressive health policy may interfere with the full realization of reciprocal human rights, further compromising access to and achievement of health. Thus, contrary to the dominant view that health is a biomedical or biocapital production of the medical industrial complex (Morrissey et al. 2019b), the realization or attainment of health is dependent upon social and environmental conditions that are themselves subjective achievements. The potentially detrimental impact of the powerful interplay between the right to health, encompassing the right to palliative care and pain relief, and human rights has been dramatically borne out in the COVID-19 pandemic. Historical pre-pandemic burdens on human rights, including rights to sanitation, water, food, shelter, a safe environment, and to be free from racial and other forms of discrimination, have had devastating effects on the progressive realization of the right to health during disaster and public health emergency crisis conditions. For example, decisions made about how resources have been allocated during the pandemic, such as uneven distribution of personal protective equipment to nursing home facilities and nursing home health-care workers, detrimentally affected the nursing home environment in which residents pursued their daily lives and the systems of care on which they depended, jeopardizing nursing home residents’ health and safety, and converting nursing homes into hotbeds of virus infection (NYSBAHLS 2020). Perhaps one of the most powerful indicia of the right to health and human rights relationship may be seen in the relationship of race and health to longevity in the United States. Research studies (Olshansky 2015; Olshansky et al. 2012) show an education-health-longevity gradient, as well as widening gaps in life expectancy demarcated by educational level and racial group membership. Such pre-pandemic inequities and their impacts upon older adults and older communities of color have only been heightened by pandemic crisis conditions. The COVID-19 pandemic presents the perfect storm largely resulting from structural inequities in the society that have marginalized Black/African American and Hispanic/Latinx older adults. A recent study on population aging in cities and counties across New York State yielded findings about older adult population growth and diversity (González-Rivera et al. 2019). There was a 26% increase over the last decade (2009–2019) in the number of New Yorkers in the 65 and over age group and a 41% rate of growth in the older immigrant population (González-Rivera et al. 2019). Of US-born older adults in New York, 31% are non-White (González-Rivera et al. 2019). Poverty rates were higher among Black/African American, Latinx, Asian American, and immigrant older adults, with poverty rates among older New York residents overall approaching 1 in 7 (González-Rivera et al. 2019). New York provides an example of the disproportionate impact of the pandemic upon older New Yorkers of color. The cumulative disadvantage of race, ethnicity, age, gender, underlying conditions, and poverty has compounded the detrimental impact of the pandemic across Black/African American and Hispanic/Latinx groups including older adults, nursing home residents, persons who are homeless living in

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shelters or who are incarcerated, immigrants, and essential workers. In New York City, disparities are glaring: Black/African Americans and Latinx are dying at twice the rate of non-Hispanic Whites (New York City 2020). Nursing homes in particular, largely segregated before the pandemic, have been crucibles of racialized suffering and racial disparities during the pandemic (NYSBAHLS 2020). At least one-third of all US COVID-19 deaths are nursing home residents or workers, and in New York, nursing home deaths are at 20% of total deaths in the state (Gebeloff et al. 2020). Of the Medicare and Medicaid nursing homes that reported data on COVID-19 cases and deaths in their facilities to the CDC, one in four had at least one COVID-19 case, and one in five had a COVID-19-related death (Centers for Medicare and Medicaid Services [CMS] 2020). Among these facilities, 188,954 confirmed COVID-19 cases and 48,215 resident deaths had been reported as of August, 22, 2020 (CMS 2020). The COVID-19 pandemic has exposed the inequities within health care, including long-term care facilities (Gebeloff et al. 2020), that disproportionately affect older adults who are members of racial and ethnic minority groups. Cumulative disadvantages and inequities experienced by Black/African Americans have resulted in disproportionate numbers of infections, illnesses, and deaths experienced by the Black/African American community during this pandemic. Black/African Americans are also experiencing higher rates of COVID-19-related infections and death than other race/ethnic groups in America (Bouie 2020).

An Intersectional Lens on Elder Abuse: Historic Inequities in Social and Economic Determinants of Health and Health Disparities Studies on elder abuse from race/ethnicity and cultural perspectives are not prevalent in spite of population aging and aging of ethnic minority groups (Jervis et al. 2016). There is also evidence that cultural norms and beliefs about abuse and tolerance for abusive behaviors intersect with race and ethnicity to increase risk for elder mistreatment (Roberto 2016; Horsford et al. 2011; Moon & Benton 2000). While most elder abuse research focuses on the general population, there is a body of research that examines elder abuse in underserved populations (Jervis et al. 2016). Small descriptive studies conducted by local area agencies on aging may include diverse subject populations, but do not build profiles for purposes of comparisons among groups of subjects defined by race/ethnicity (Brownell et al. 2000). Whether minority populations in question are considered to be oppressed, marginalized (Walsh et al. 2010), or underserved (Jervis et al. 2016), there is common agreement that racial/ethnic disparities exist for minority groups leading to cumulative disadvantages (Swinford et al. 2020) in health care, economic security, safe housing, quality care, and well-being (Maudlin et al. 2020). Prevalence studies on elder mistreatment, when they have included race/ethnic diversity in study samples, do not uniformly find significant difference in relative risk of abuse among White and minority subjects (Hernandez-Tejada et al. 2013). However, other studies have

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identified an intersection between underserved populations and discrimination, cultural factors including perceptions of what could be termed abuse, and poverty (Jervis et al. 2016). In addition, some communitarian values shared by minority older adults, such as the importance of family and faith, can represent strengths but also vulnerabilities. These can lead to unwillingness to disclose abuse for fear of shaming one’s family and community, as well as perceived cultural expectations of helping other family members with resources, and can hinder help-seeking for older adults who experience abuse and neglect by family members and loved ones (Sanchez 1997). Institutional abuse and neglect have been studied in long-term care facilities, using an ecological model that could lend itself to inclusion of race/ethnic variables. However, the focus of these studies generally has not encompassed disparities in health care and underlying health conditions, nor contributing factors such as employment, economic security, and housing (Schiamberg et al. 2011).

Elder Mistreatment and Black/African Americans: Research Findings Public policies, institutional and social practices, ideologies, and other norms have been found to work in ways that create, reinforce, and reproduce inequities among groups of people. Efforts are needed to address the underlying conditions that exacerbate the racial disparities in health outcomes in Black/African American communities in the United States, including structural racism at the root of these disparities. Due to factors associated with social and economic determinants of health, people with chronic illnesses are disproportionately represented in communities of color and low-income communities (Savin and Guidry-Grimes 2020), placing this segment of the population at greater risk of experiencing severe COVID-19. Black/African Americans are disproportionately affected by COVID19 in infection rates, hospitalizations, and deaths (Swinford et al. 2020). The pandemic has made conditions of suffering that challenge the foundations of our society, such as institutional neglect, poverty, and isolation, that much worse, and little is yet known about the social character of institutional and family violence against older adults behind closed doors during virus-enforced quarantines and lockdowns (AGE Platform Europe 2020). It is time to broaden the range of inquiry into the safety of older adults living in diverse racial/ethnic communities. Although elder abuse research on race/ethnicity is still limited (National Center on Elder Abuse – NCEA 2014), findings suggest that it is influenced by risk factors and protective factors that encompass individuals, families, and communities. This is particularly relevant in the contexts of the social ecological model of research and inquiry (Morrissey et al., 2019b). Compared to those older adults who are nonHispanic White, Latinx, or Asian or who do not identify as members of Black/ African American communities, Black/African American older adults are disproportionately affected by financial exploitations and psychological mistreatment (NCEA 2014). Comparing perceptions of elder abuse among Black/African

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American, Korean, and non-Hispanic White older adults (Moon & Benton 2000), Black/African American older adults were found to be more likely to perceive situations as abusive when compared to other ethnic groups (NCEA 2016; Tauriac & Scruggs 2006). In addition, financial strain in Black/African American households may place Black/African American older adults at risk of being financially exploited. Beach et al. (2010) found that Black/African Americans were more likely to report other family members (non-spouses) as psychologically abusive. Intersecting levels of individual, family, and community factors suggest that the ecological and cultural frameworks are best suited to understanding risk and protection for elder abuse within the Black/African American community (Horsford et al. 2011).

Mistreatment and Latinx Older Adults Mistreatment of Latinx older adults has not received sufficient attention from elder abuse researchers (Para-Carrdona et al. 2007). However, an ecological and culturally relevant theoretical framework for understanding elder abuse within this population is key, especially in the context of the disproportionate impact of COVID-19 on Latinx. While Latinx are the fastest-growing ethnic minority in the United States, according to the US Census Bureau, there is still limited knowledge about abuse and exploitation experienced by Latinx older adults. Even though language is one barrier to research on this population, the diversity among communities of Latinx (Mexican, Puerto-Rican, Cuban, Dominican, Salvadorian, and other Hispanic or Latinx immigrants) is another (National Center on Elder Abuse 2014). Some limited research has found that Latinx were less likely than other race/ethnic groups to report both verbal and financial mistreatment. However, a significant proportion (40%) of older adult respondents, according to a 2008 prevalence study by Laumann (2008), reported experiencing at least one type of abuse, and 21% reported experiencing multiple forms of abuse (polyvictimization), including physical, psychological, and sexual exploitation and caregiver neglect. Very few respondents stated they reported the abuse to law enforcement, adult protective services, or other authorities. Evidence exists that cultural norms and beliefs about abuse and tolerance for abusive behaviors intersect with race and ethnicity to increase risk for elder mistreatment (Roberto 2016; Horsford et al. 2011; Moon & Benton 2000; NCEA 2014). Cultural values about responsibility to one’s family, or familism, reflected by Latinx older adults included priority placed on the needs of the family unit as more important than those of individual family members. Latinx older adults identified a preference for in-home over institutional care and prioritized the needs of the family over their own needs (NCEA 2014). They were also found to be less likely than some other race/ethnic groups to define financial abuse as a form of elder mistreatment (Sanchez 1997). Latinx older adults were also more likely to report intimate partner abuse, reflecting a strong emphasis on machismo in that culture. Efforts are needed to better understand and address the intersection of the individual, relational, cultural, and societal factors that place Latinx older adults at increased vulnerability for abuse.

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Mistreatment of American Indian Elders American Indian reservations are struggling with the effects of infection on health as well as economic and food insecurity of its members (Morales 2020). COVID-19 has taken its toll on tribal communities like the Navajo Nation, which, if it were a state, would rival New York City for prevalence of infections (Morales 2020). Congregate gatherings like church services, poor communication channels due to lack of Internet and cellphone use, and poor access to fresh food and clean water necessitating trips to stores that do not enforce social distancing are blamed. Health care is underfunded, and cultural values that compel intergenerational household members to care for sick loved ones exacerbate spread of infections (Morales 2020). The earliest research studies on elder abuse and neglect among American Indians were conducted with a Navajo tribal community (Brown 1989). In these early studies, neglect and economic exploitation were the most prevalent types of abuse identified. Economic exploitation, however, was not endorsed by older tribal members as abuse because sharing resources was defined as a cultural privilege and duty to families. This highlights the challenge of conducting elder abuse research with American Indian tribal communities: cultural nuances on what constitutes abuse, sensitivity of the topic, diversity among Native groups, and distrust of researchers who are considered outsiders (Jervis 2014). Because of divergent perspectives on what constitutes elder abuse between the research community and American Indians, particularly Native elders themselves, qualitative research on perceptions of abuse conducted collaboratively is considered most relevant (Jervis et al. 2017). Respect is key to American elders’ conceptualization of good treatment of older persons, and financial exploitation for money, labor, or housing predominated discussions of poor treatment (as well as theft, exploitative childcare, and inappropriate demands for care made by adult children) (Jervis et al. 2017). Neglect is defined as other family members not anticipating and providing for elders’ care needs and placing elders in nursing homes. In general, Native elder mistreatment is viewed as situated within the extended family, and family stressors including substance abuse, poverty, and intra-familial conflict are frequently cited as causes of elder mistreatment (Jervis et al. 2017).

Elder Mistreatment of Asian-American Older Adults Research on mistreatment of older adults from the Asian-American community has been significantly advanced by scholars like XinQi Dong and his team from the Chicago area and by Ailee Moon and her students from the University of California/ Los Angeles. Dr. Moon pioneered comparative studies on perceptions of elder mistreatment among different race/ethnic communities, including Korean Americans (Moon & Benton 2000). In her initial qualitative study, she demonstrated that representatives of diverse race/ethnic groups defined elder mistreatment differently, based on different cultural lenses. In the context of COVID-19, issues of discrimination against older Asian Americans are critically important.

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Cross-cultural comparisons of Asian Americans from different Asian countries and cultures further refined an understanding of cultural differences that mediated perceptions of abuse (Lee et al. 2014). One study on mistreatment, culture, and helpseeking found that elder abuse is a culturally laden construct and that core values affect perceptions of abuse. In this study example, older Korean study participants compared to Chinese older adults were more strongly influenced by hierarchy and cultural beliefs in family ties and gender norms and were less likely to disclose abuse; this has implications for developing more effective culturally based interventions (Lee et al. 2014). While acknowledging the limited nature of studies on elder abuse among Korean Americans, Chang (2016) interviewed 200 older Korean Americans in the Los Angeles area and found that, among that universe, 58.3% noted experiencing one or more types of abuse. Victims’ health status and educational levels predicted likelihood of abuse in this non-random study sample. To examine the cultural definition of financial abuse among Korean American older adults, Lee and her team (2012) interviewed a non-random sample of older adult Korean American immigrants to determine how they defined financial abuse in their community. Findings indicated that those with stronger adherence to culturally defined traditional values were more likely to define financial abuse as adult children failing to support elder parents financially, a definition that is generally not considered in surveys on elder abuse (Lee et al. 2012). Acculturation or length of time individual immigrants have lived in their new country is considered an important measure of the extent to which they have left behind the cultural values of their country of origin and internalized those of their adopted country (Shibusawa and Yick 2007). Intimate partner violence (IPV) is considered normative as a gendered act in many traditional Asian societies. Shibusawa and Yick (2007) interviewed older Chinese-American respondents of a larger West Coast database and found that those subjects who are less acculturated are less likely to view physical violence as domestic violence and more likely to believe that a husband’s violence toward his wife is justified (Shibusawa and Yick 2007). XinQi Dong (2015) has published a comprehensive analysis of research conducted on elder abuse and Chinese populations globally (Dong 2015), as well as numerous studies conducted in the Chicago area in the United States. He and his team note that depression and elder abuse and neglect are common among urban community-dwelling Chinese older adults and depression is a significant risk factor for elder abuse (Dong 2008), highlighting the intersection of elders’ mental health and vulnerability to abuse and neglect.

Palliative Care as Public Health Policy Response and Intervention: Mitigation of Older Adult Risk and Suffering in Pandemics The Institute of Medicine Crisis Standards of Care (2012) draw attention to the central role of palliative care in disaster and public health emergencies and are directly applicable to the COVID-19 declared disasters and public health

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emergencies, pandemic crisis conditions, and concomitant older adult population risk and suffering. Palliative care is both a philosophy of medical and social care and a delivery system and intervention that has advanced evidence-based practices in the relief of suffering and pain and symptom management. In pandemic crisis conditions when the demand for resources may exceed supply, there is an ethical obligation to ensure that no older adult is abandoned in unmitigated pain or unrelieved suffering. Equitable access to pain management and other palliative care strategies to meet the needs of all older persons, including older adults’ psychosocial needs, is essential. As a public health policy response to suffering in advanced illness and associated social care need, palliative care is a right of older adults, consistent with international frameworks. The United Nations Committee on Economic, Social and Cultural Rights Comment 14 recognizes the right to health as the highest attainable standard of health (United Nations 2000). The Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (Hunt 2007) spells out the right to health as, “a right to an effective and integrated health system, encompassing health care and the underlying determinants of health, which is responsive to national and local priorities, and accessible to all” (Hunt 2007, p. 2). As explicated further by Gostin (2014), Comment 14 (Hunt 2007) specifies the normative content of the right to health, including rights to palliative care and pain management: availability, accessibility, ethical and cultural acceptability, quality, and the non-discriminatory provision of health facilities, goods, and services. The Global Palliative Care Atlas (Connor and Sepulveda Bermedo 2014) clarifies that while Comment 14 contains no expressed reference to palliative care, the normative content of the right to health is inclusive of palliative care and pain management and encompassed within the core obligations of all signatory nations without regard to nations’ resources: “access to health facilities, provision of goods and services on a nondiscriminatory basis, the provision of essential medicines as defined by the WHO, and the adoption and implementation of a public health strategy” (Connor and Sepulveda Bermedo 2014, p. 9). It is clear that even in the absence of a constitutional right to health care, such as in the United States, nation states are obligated to operationalize the right to health under international law. The UN Special Rapporteur on torture has cognized that, “denying access to pain relief can amount to inhuman and degrading treatment” (Connor and Sepulveda Bermedo 2014, p. 9). Older adults from diverse backgrounds and communities face multiple threats to their health and social welfare, ranging from food and income insecurity to health, housing, and other social and economic disadvantages and risks of elder abuse, neglect, and violence (Morrissey et al. 2015). Ensuring the right to health requires health systems that are accessible and systems approaches that respond to the ways in which structural factors, social practices, ideologies, forms of systemic discrimination and racism, and other norms work to reinforce and reproduce inequities among underrepresented and marginalized groups. One example of a systems approach to addressing and relieving older adult suffering, especially in pandemic crisis conditions, is building palliative environments (Morrissey et al. 2015) that ensure older adults’ rights to palliative care and pain management are

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operationalized systems-wide and leave no one behind, such as in nursing home facilities. In order to address the exigent circumstances created by the disproportionate impact of COVID-19 on Black/African American and Hispanic/Latinx older adult populations and communities, including nursing home residents and older health-care workers, and consistent with the IOM’s Crisis Standards of Care (2012), the New York State Bar Association Health Law Section (2020) has recommended equitable access to palliative care as an ethical minimum in the mitigation of suffering of vulnerable populations including older adults.

International Palliative Care Frameworks: The Public Health Strategy The World Health Organization (WHO) definition of palliative care frames the person-centered goals of palliative care and describes palliative care services as an approach that aims to improve the quality of life of patients and their families who are dealing with life-threatening illness. Under the WHO definition, the systems approach to palliative care encompasses both prevention and relief of suffering through early identification and comprehensive assessment and treatment of pain, as well as physical, psychosocial, and spiritual needs (World Health Organization 1990). Building on the WHO framework, the Public Health Strategy (PHS) for Palliative Care maps out an agenda for translating scientific knowledge and evidence into effective population-level interventions and practices for relieving suffering and improving quality of life that is relevant to older adults with serious illness and suffering. This is especially true in light of older adults’ heightened suffering and risks of abuse, neglect, and violence during pandemics. The key components of the PHS encompass development of national policies and regulations; assuring adequate drug availability; health-care worker and public education and training; and implementation of policy through strategic infrastructure, standards, and guidelines (Stjernswärd et al. 2007). The World Health Assembly Resolution WHA 67.19 (World Health Assembly, 2014), “Strengthening of palliative care as a component of comprehensive care throughout the life course,” advances the WHO and Public Health Strategy frameworks in the progressive realization of palliative care as a right (Morrissey et al., 2019a; Morrissey et al., 2019b)). The WHO Program Operations Manual (“Manual”) charts a plan for implementing palliative care programs and best practices on the ground (World Health Organization 2016). The Manual builds on the WHO palliative care framework, explicitly spelling out the obligation of nation states to provide basic palliative health services and social protection systems: Palliative care is the prevention and relief of suffering of any kind – physical, psychological, social, or spiritual – experienced by adults and children living with life-limiting health problems. It promotes dignity, quality of life and adjustment to progressive illnesses, using best available evidence. . .All people, irrespective of income, disease type, or age, should

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have access to a nationally determined set of basic health services, including palliative care. Financial and social protection systems need to take into account the human right to palliative care for poor and marginalized population groups. (World Health Organization 2016, p. 45)

The 2017 Lancet Commission report (Knaul et al. 2017) on palliative care, addresses palliative care health-related interventions in the contexts of end-of-life, life-threatening, or life-limiting illness or conditions, and more specificallly, the moral obligations of global public health systems in situations of extreme suffering, unrelieved pain, poverty, and inequity across the world, particularly developing countries. The Commission (Knaul et al., 2017) identifies palliative care and pain relief as essential universal health coverage and social provision benefits, and introduces a new measure of suffering called “serious health-related suffering.” This measure targets illness or injury of a serious nature and physical, emotional, or social suffering, that cannot be relieved without professional intervention (Knaul et al., 2017). Consistent with the World Assembly Health Resolution (2014) and recommendations for palliative care policy and implementation strategies, the Commission outlines essential palliative care and pain relief, and social services and supports, resources, and interventions that would mitigate serious health-related suffering. Most recently, the Lancet (2020) has called attention to the omission of palliative care from the WHO COVID-19 guidance, and the detrimental consequences of this omission in terms of limiting access to palliative care and pain relief for those who have experienced high suffering burden during the pandemic as the result of COVID-19 related illness, including older persons. These recommendations are relevant to the pandemic environment and the suffering of older adults (Morrissey 2015), both suffering associated with severe COVID-19 illness and the concomitant heightened elder abuse risk during pandemic crisis conditions. The suffering of older adults demands a comprehensive humanitarian public health response that goes beyond COVID-19 testing and treatment if positive test results. Rapid response in the form of robust public health policy making and implementation of policy that mitigates risk and suffering of older adults are an ethical imperative. Such policy responses must include equitable allocation of scarce resources to vulnerable older adults and adequate funding of integrated health and social care across the continuum of care, from nursing homes, adult care facilities, assisted living residences, prisons and places of detention to communitybased settings. In understanding vulnerability in the era of COVID-19, Ahman et al. (2020) state that, although the needs of vulnerable groups must be accounted for in health policy and practice at the frontlines of the crisis, these needs reflect existing contextual, rather than individual, injustices. Addressing needs of underserved and marginalized groups will require an understanding of the lived experience of older persons as situated within cultures, communities, and in particular social groups, as well as recognition and reparation of the sociocultural, sociopolitical, and sociohistorical ruptures that generate vulnerability within specific categories of marginalized groups (Ahmad et al. 2020; Morrissey et al. 2019b). Such a shift will involve addressing the conditions of older adults’ embedded environments, modifying social

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and economic determinants of health, and eliminating systemic discrimination and racism. According to Gostin (2014), this means ensuring that comprehensive health goods, services, and facilities are made available, accessible, affordable, and acceptable, both ethically and culturally, and equitably distributed (Morrissey et al. 2019b).

Universal Instrument to Promote Human Rights of Older People (Convention) Dialogues have been initiated at the United Nations by older adult activists to discuss goals and strategies toward achieving an international treaty document to promote and protect the rights of older adults (Levittan et al. 2021). In a statement on older people and the detrimental impact of COVID-19, the United Nations Secretary General has called attention to the goal of developing an international legal instrument that would afford human rights protections to older persons (United Nations 2020). The disproportionate effects of the COVID-19 pandemic on older adults around the world, compounding pre-existing inequities and health disparities, underline the critical importance and urgency of promoting and protecting older adults’ human rights in the progressive realization of the right to health.

Key Points • The COVID-19 disaster and public health emergency have heightened risks of elder abuse and older adult suffering and precarity across diverse communities and magnified the growing older adult humanitarian crisis. • The disproportionate impact of COVID-19 on vulnerable older adults and older people and communities of color has exposed the persistence of historical inequities in access to the society’s resources and disparities in health outcomes. • An intersectional lens on elder maltreatment, abuse, and neglect, and their social and economic determinants, illuminates the variations in social and cultural norms and attitudes toward elder abuse and long-standing racial and other inequities in treatment of older adults across diverse populations. • Human rights, global health, and systems frameworks are critical to the progressive realization of the right to health, palliative care and pain relief for all older persons and the elimination of systemic discrimination and racism. • The public health strategy for palliative care is a promising evidence-based intervention and set of practices that will help to build professional, organizational, and community capacities to reduce suffering burden and risks of older adult neglect, abuse, and violence, and to foster resilience, recovery, and the building of supportive palliative environments that will enable and enhance older adult life-world flourishing both during the crisis conditions of pandemics and in older persons’ future lives and pursuits.

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Conclusion Global health, human rights, and systems frameworks guide policy making in the progressive realization of the right to health, palliative care and pain relief and human rights for older persons. Comprehensive public health policy planning and a public health strategy for palliative care hold the greatest promise for reducing risks of neglect, exploitation, abuse, and violence among vulnerable older adults and fostering resilience, not only during public health emergencies and disasters but in post-disaster recovery and for the future.

Cross-References ▶ Caregiving and Elder Abuse: A Complex Relationship ▶ Elder Abuse in Asia ▶ Intersectionality of Elder Abuse and Mental Health Issues: Needs and Interventions for Victims ▶ Intimate Partner Violence in Later Life ▶ Neglect and Self-Neglect of Older Adults ▶ Perpetrators of Elder Abuse ▶ Polyvictimization and Elder Abuse ▶ Recognizing the Trauma Experienced by Community-Dwelling Older Victims of Financial Abuse Perpetrated by Trusted Others ▶ Sexual Victimization of the Elderly: An Examination of the Emergent Problem ▶ Suicidality and Interpersonal Violence ▶ Systems Responses to Older Adult and Elder Abuse

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Section XXIII Future Directions in Interpersonal Violence and Abuse Across the Lifespan Robert Geffner, Jacquelyn W. White, L. Kevin Hamberger, Alan Rosenbaum, Viola Vaughan-Eden, and Victor I. Vieth

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Tracy Sbrocco, Khalilah M. Mccants, Megan W. Blankenship, Michele M. Carter, and Patrick H. Deleon

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Incorporating Advocacy and Policy into the Behavioral Health Professions . . . . . . . . . . . . . . . . . Moving Back and Forth: Marrying Science and Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . An Interprofessional Obligation to Advocate for Communities in Need . . . . . . . . . . . . . . . . . . Formal Incorporation of Policy into Behavioral Health Training Models . . . . . . . . . . . . . . . . . Formal Training Requirements Targeting Interpersonal Violence . . . . . . . . . . . . . . . . . . . . . . . . . The Impact of Interpersonal Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Understanding Interpersonal Violence Leads to Prevention and Mitigation . . . . . . . . . . . . . . . . . . Recognizing Social Determinants of Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Managing Multiple Determinants in Prevention and Mitigation Strategies . . . . . . . . . . . . . . . Personal Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Effective Advocacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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The views expressed are those of the authors and do not reflect the official policy or position of the Uniformed Services University, the Department of Defense, or the US Government. T. Sbrocco (*) · M. W. Blankenship Department of Medical and Clinical Psychology, Uniformed Services University, Bethesda, MD, USA e-mail: [email protected]; [email protected] K. M. Mccants Daniel K. Inouye Graduate School of Nursing, Uniformed Services University, Bethesda, MD, USA e-mail: [email protected] M. M. Carter Department of Psychology, American University, Bethesda, MD, USA e-mail: [email protected] P. H. Deleon Daniel K. Inouye Graduate School of Nursing and F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, MD, USA © This is a U.S. Government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_306

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Concluding Reflections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4749 Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4750 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4751

Abstract

As interpersonal violence continues to plague communities across the USA, behavioral healthcare providers and scientists have established effective treatments for victims while seeking to understand social determinants and develop strategies for prevention. In this chapter, we present a collection of diverse perspectives which reveal the causes and consequences of violence within certain cultural groups along with current initiatives for change. Yet, scientifically supported strategies to reduce violence are often slow to be implemented particularly due to the disconnect between scientists, behavioral healthcare providers, policy makers, and impacted communities. Effective advocacy is a skillset that bridges the disconnect between stakeholders and encourages collaboration between providers and legislatures. It is not only our responsibility to engage in effective advocacy toward strategies that reduce violence, but also to encourage and teach this necessary skillset to the next generation of behavioral healthcare providers and scientists. Keywords

Interpersonal violence · Violence prevention · Culture · Advocacy · Policy change · Lawmakers · Behavioral healthcare providers

Introduction An estimated ten million Americans are affected by interpersonal violence every year (Huecker and Smock 2020). There can be little question that our nation’s behavioral health practitioners, educators, and scientists can make a significant contribution to addressing the many complex issues surrounding interpersonal violence. Throughout this chapter, we attempt to educate the readership as to the importance of thinking outside of one’s historical comfortable silo and actively engaging with those who, in reality, actually craft and implement our nation’s social (including healthcare) policies. Forming collegial relationships, having a long-term vision; being present, as well as persistent; and learning how to effectively communicate with colleagues possessing fundamentally different professional backgrounds, cultures, and assumptions are absolutely critical. In addition, it is time for us to systematically expand our influence outside of the clinic to engage with policy makers to address what is our ultimate goal – prevention of violence and mitigation of the biopsychosocial ecological circumstances that place communities at risk. At the end of the chapter, we bring personal perspectives and stories on violence and training in policy and the political process. All in all, these perspectives are designed to illustrate that there is not a one-size-fits-all model to understand, prevent,

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and mitigate violence and to heal communities. Rather, we must view violence through many lenses and consider retooling our education and training in behavioral health to target specific strategies to identify and address interpersonal violence from both our role as traditional providers and expanded into our role in policy and advocates.

Incorporating Advocacy and Policy into the Behavioral Health Professions In many ways, the mental health professions can be considered to be only in their early adolescence in becoming involved in the public policy/political arena (Sammons and VandenBos 2019). Historically, one can see a slow but steady evolution from the early days of basically ignoring those with mental illness to the persuasive efforts of Dorothea Dix in the 1840s in lobbying for better living conditions for those requiring mental health treatment, resulting over a 40-year period in persuading the US government to fund the building of 32 state psychiatric hospitals (Schimmels et al. in press). With the introduction of psychotropic medications, society’s postwar embracement of more liberal and civil-rights orientated views, both of which contributed significantly to the deinstitutionalization movement, and the historic vision of Presidents John F. Kennedy and Lyndon B. Johnson, the exciting era of the Great Society ushered in an unprecedented expectation for growth and positive change, at least at the individual patient/consumer level. Over this time period, the absolute number of nonphysician mental health (now more commonly designated as behavioral health) care providers dramatically increased. Equally, if not in the long run more importantly, their educational institutions evolved to provide doctoral level training. And, also during this period, the dramatic and unprecedented changes occurring within the communications and technology fields increasingly impacted the nation’s healthcare environment (IOM 2012). Along with these developments, a maturing interest has come in having an exciting and robust science base directly impacting our nation’s social policies. In reviewing the recent Presidential reflections for the American Psychological Association (APA) and that of the American Academy of Nursing (AAC), both Rosie Phillips Davis and Karen Cox called for their members to become more personally involved in addressing society’s pressing needs. For the former, this was ending deep poverty; for the latter, this was integrating the social determinant of health into nursing education. To be successful, these efforts would require establishing ongoing collaboration between their field’s science and the public and private sectors through advocacy efforts, user-friendly science-based resources, and partnerships to effect population-level change. These are not new concepts for either profession. In 1969, in his APA Presidential address, George Miller called for Giving Psychology Away. “Our responsibility is less to assume the role of experts and try to apply psychology ourselves than to give it away to the people who really need it (p. 1071).” More recently, 2008 APA President Alan Kazdin

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expressed that his goal was bringing to bear the talent of APA members and resources to have a lasting impact. He pursued three major initiatives: articulate psychology’s contribution to the grand challenges of society; addressing interpersonal violence; and addressing posttraumatic stress disorder and trauma in children and adolescents and the National Partnership to End Interpersonal Violence Across the Lifespan (NPEIV) grew from this presidential initiative (DeLeon and Kazdin 2010). And, as we have already noted, Dorothea Dix successfully sought to bring nursing expertise into the public policy domain. From an educational perspective, one might consider each of these approaches as embracing a broad public health perspective.

Moving Back and Forth: Marrying Science and Policy Over the years, the behavioral health professions have developed an impressive scientific knowledge base surrounding the critical issues of preventing violence and related social issues, especially among our nation’s children and youth (NASEM 2019a, c). And yet, one must conclude that at the practical, day-today experiential level, very little of this expertise is being systematically utilized. One must wonder, therefore, what are the underlying causes; not of violence per se, but instead, why these decades of quality research findings are essentially being ignored? In a related quest, while exploring ways in order to ensure that all children in our nation possess the opportunity to meet their full health potential and lead fulfilling lives, a committee of the National Academies of Sciences, Engineering, and Medicine (NASEM) noted: “reviewing the scientific evidence for how to translate the best science into action to positively impact health during early childhood, we strove to close the disconnect between evidence and practice in our nation today. While some scientific evidence has laid the groundwork for actionable practice, policy, and systems solutions, other emerging scientific findings are ripe for future research and inquiry. The committee also acknowledged that achieving and sustaining health equity is a long-term goal with many interrelated strategies and tactics. Thus, we included some recommendations that can be feasibly implemented more quickly by a focused group of actions, while other recommendations may take longer and will require broad support from many different actors at all levels of society” (NASEM 2019c, p. xvi).

An Interprofessional Obligation to Advocate for Communities in Need Accordingly, we would rhetorically ask: What could the behavioral health professions do that they have not already tried? Their extensive education has been heavily subsidized by society. Upon graduation, as professionals, their overall quality of life is far better than most citizens in our country. In essence, our nation’s healthcare professionals and academic educators and scientists represent society’s educated

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elite, regardless of their specific discipline. As such, they have a societal obligation to provide effective and visionary leadership. It is simply unacceptable for any of the health professions to sit back and opine that preventing violence in today’s society – especially within the historically underserved and neglected populations – is the responsibility of others. Although there has been growing attention to the importance of interprofessional training (IPE) (DeLeon et al. 2015; IOM 2015), most of the health professions unfortunately continue to train their next generation in isolated silos, notwithstanding the express recognition of this evolving movement in President Obama’s landmark Patient Protection and Affordable Care Act (ACA). Senior educators, scientists, and practitioners overwhelmingly tend to reflect the values and experiences to which they were exposed during their early training years. Clearly, there is a need for academic educators to take responsibility for better preparing professionals to respond to interpersonal violence and to break out of their professional silos. Models for interprofessional education and training targeting interpersonal violence exist and are growing, particularly related to child abuse. Both NPEIV and the Zero Abuse Project have been instrumental in implementing interview training programs and developing a 21-credit minor where psychology, nursing, social work, criminal justice, and other students learn together how to respond to cases of child abuse (Vieth et al. 2019). It is also important to appreciate the significance of the reality that over the years the majority of federal elected officials have possessed a legal (i.e., law) background, thereby being exposed in-depth to its unique language, culture, and approach to addressing complex policy issues, and history. Similarly, very few healthcare professionals have been personally exposed to the traditional career path of those seeking elected office or appointment to high-level administrative positions. By remaining isolated from other professions during these career shaping years, we have found that very few psychologists or advanced practice-registered nurses (APRNs) have any personal appreciation for the nuances of the public policy/ political process. In reflecting upon these two worlds, former APA Congressional Science Fellow and Congressional staffer Neil Kirschner opined: “More often than not, research findings in the legislative arena are only valued if consistent with conclusions based upon the more salient political decision factors. Thus, within the legislative setting, research data are not used to drive decision-making decisions, but more frequently are used to support decisions made based upon other factors. As psychologists, we need to be aware of this basic difference between the role of research in science settings and the legislative world. It makes the role of the researcher who wants to put ‘into play’ available research results into a public policy deliberation more complex. Data needs to be introduced, explained, or framed in a manner cognizant of the political exigencies. Furthermore, it emphasizes the importance of efforts to educate our legislators on the importance and long-term effectiveness of basing decisions on quality research data. . .. If I’ve learned anything on the Hill, it is the importance of political advocacy if you desire a change in public policy” (Kirschner 2003).

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Formal Incorporation of Policy into Behavioral Health Training Models Thus, one of the major educational policy quandaries: How do the behavioral health professions maintain their exceptional, and admittedly already quite lengthy, training models, while at the same time developing internal expertise within their next generation of the importance of, and uniqueness of, the public policy process and its culture? Should psychology, for example, continue to rely upon those colleagues who, essentially on their own, decide to become personally involved in the critical policy-setting process? Should psychology and nursing faculty be encouraged to codevelop courses, or at minimum timely training experiences, for their university’s law schools? What should be the role of state psychological and nursing associations? We have yet to learn of any ongoing efforts by any state psychological association to develop joint annual programs with their counterpart bar, nursing or social work, or public health associations. We are aware of senior psychologists who have served on judicial selection bodies. Ted Strickland was the first psychologist to be elected to the House of Representatives and then went on to become Governor of the State of Ohio. However, once again, this relies upon individual initiatives and contacts, rather than representing a systematic approach. Accordingly, we would again rhetorically ask: Is it not the societal responsibility of our nation’s educated elite to develop effective approaches to ensuring that the most up-to-date scientific knowledge is actively considered in developing relevant public/social policies?

Formal Training Requirements Targeting Interpersonal Violence In the international arena, the World Health Organization (WHO) stipulates ways in which healthcare providers within the health system should respond to victims of interpersonal violence. The strategy that healthcare providers should operationalize is as follows: properly identify the occurrence of, or risk for, interpersonal violence; contribute to an increase in access to quality care for prevention or treatment of individuals at risk or exposed to interpersonal violence; encourage the early detection of interpersonal violence through case management and quality improvement initiatives within the healthcare system; encourage and administer primary and tertiary education to empower individuals to be autonomous; and provide accurate documentation in hospital and other appropriate records and advocacy.

The Impact of Interpersonal Violence Clearly, there is a global need to reduce the extraordinary mortality rate of more than 520,000 individuals annually as a result of interpersonal violence. The 2011 mortality rate from interpersonal violence was 35.3%. The mortality rate from interpersonal violence in a low-income country is 8 per 100,000 people, compared to a high-income country where the rate is 3.3 per 100,000. Within that total

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estimate, over 73% took place in a low- and middle-income country (Brotto et al. 2017). Even when death is not the final outcome, the impact of interpersonal violence remains devastating because the resulting long-term suffering and trauma interrupts an individual’s physical, mental, and sexual baseline, not to mention that of their family members. Interpersonal violence has been conceptualized as one of three forms of violence. Self-directed violence (including suicide) and collective violence (to include war, terrorism, torture, or genocide) are considered the other two forms of violence (Mercy et al. 2017). Interpersonal violence is further categorized as intimate/family violence or community violence. This means harm that can be physical, psychological, or sexual in nature is inflicted onto another person. Kelly (2014) states that interpersonal violence is the intentional harmful physical engagement against another individual. The authors include the use of social media for the purposes of misrepresenting another individual or maintaining exclusive peer groups to the detriment of another’s feelings as examples of interpersonal violence. In the community, interpersonal violence can be bullying, rape, assault (to include sexual), and youth violence carried out by a random or known individual at work, in school, or in prison. Intimidation/ retaliation can be a major consequence. We are aware, for example, of student victims being accused by administrators of “asking for it” since they allegedly were wearing provocative clothing and then having their grades lowered for reporting the incident. Another form of interpersonal violence is intimate/family violence which includes poor treatment of the geriatric population, and/or the abuse of power or physical force on the pediatric population. Interpersonal violence is the leading cause of death for the pediatric population. Further, a significant proportion of children are also negatively impacted by being exposed to interpersonal violence. Therefore, proper identification is imperative and requires that healthcare providers recognize the signs. Healthcare providers who understand the risk and/or protective factors will be effective in reducing the incidence of interpersonal violence, as well as how one might incorporate the appropriate screening questions in order to be laser focused on the presenting issue (s) at the bedside (Juarez 2020). Healthcare providers should be especially aware that in children 2–14 years of age, 76% experienced some form of physical or emotional violence in the prior month. From a global perspective, in Hatti, Kenya, Tanzania, and Zimbabwe 26–38% of girls were victims of sexual violence, while 9–21% of victims were boys. The rate of physical violence against girls was 61–74% and 57– 67% for boys. Psychological violence against girls occurred 24–35% of the time compared to 27–39% in boys (Mercy et al. 2017). The WHO estimated the costs associated with interpersonal violence occurrences worldwide reached 3.3% of the Gross Domestic Product (GDP). Child abuse alone totaled $94 billion annually, which is the equivalent of 1% of the GDP. The cost of treating an individual patient as a result of child abuse was estimated at $13,781–42, 518. If interpersonal violence should be the chief complaint, the annual cost was estimated to be $12.6 billion or 0.1% of the GDP (Waters et al. 2004, WHO 2014). One should appreciate that successful advocacy can have huge economic

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implications. For example, by advocating for a program that offered housing for victims of domestic violence in the 1994 Violence Against Women Act (reauthorized in 2019), the USA experienced a cost saving of $14.8 billion and a net benefit of $16.4 billion.

Understanding Interpersonal Violence Leads to Prevention and Mitigation In 2015, Montesanti and Thurston found that theoretical frameworks are useful for guiding the practice of healthcare providers as these frameworks can be used to help comprehend the factors that influence interpersonal violence. For example, the exogenous factors that increase the likelihood of interpersonal violence against women are demonstrated by their Ecological Framework to Study Women’s Health where the three systems of healthcare (micro, meso, and macro) are defined and provide insight into the vulnerability of women to interpersonal violence. And the National Institute of Minority Health and Health Disparities (NIMHD) has refined such psychosocial-ecological models to characterize the multiple levels at which to understand and intervene on the social determinants, including the healthcare system, and examine the interplay of these determinants across the lifespan (PerezStable and Collins 2019). A literary yet fictitious account of interpersonal violence against women guided by customs is told through Pulitzer-Prize winning author, Alice Walker’s novel, Possessing the Secret of Joy. This story follows a tribal African woman who consensually undergoes pharaonic circumcision owing to her obligation to her culture and tradition. This type of violence is typically carried out by a known assailant and takes place in homes.

Recognizing Social Determinants of Violence Proper identification of potential interpersonal violence is imperative. This requires that healthcare providers especially recognize those social determinants that increase the risk of interpersonal violence taking place, such as disparities within the socioeconomic realm, the age and gender of the individual, employment status, equitable education, and environmental stability. For example, during triage, a patient indicating an issue with the aforementioned categories should be flagged for further evaluation in order to address any underlying problems strongly correlated with violence (Niolon et al. 2017). It is also the responsibility of the healthcare provider to identify the resulting intrapersonal physiological disruption from interpersonal violence, coupled with the systematic discrimination at the macro level (Humphreys et al. 2005). Access to care has historically been a significant issue. Heise (1998) developed the social-ecological model of health to outline the related factors that serve as either an enabler or barrier to healthcare access. More recently, the NIMHD has incorporated the healthcare system itself as a social determinant of health. Access to care is

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linked to an individual’s relationships at the interpersonal level. Therefore, healthcare providers must be sensitive to remaining within reach of the population they serve in an unobtrusive way, allowing the individual to retain some form of anonymity outside of government regulations. Interpersonal violence all too often goes unreported (Koss and Gaines 1993). Utilizing the psychopathological instruments that are typically accessible at larger hospitals should be incorporated into the healthcare providers’ standard protocol (Moreno et al. 2016) and early detection of victims of interpersonal violence should be accomplished through comprehensive screening. In accordance with the Affordable Care Act requirements, interpersonal violence screenings are a covered service by both medicaid expansion (Ramaswamy et al. 2019) and private plans.

Managing Multiple Determinants in Prevention and Mitigation Strategies Contributing factors that increase the incidence of child maltreatment, suicide, and/or homicide include the use of illicit substances and/or excessive alcohol use. Accordingly, discharge planning should include guidance for cessation and/or reducing the use of said aggravators. Case management, the overarching field that encompasses discharge planning, is a basic hospital healthcare system function and federal government mandate (McCants et al. 2020). The healthcare provider should be especially cognizant of the outcome of cognitive disorders that interpersonal violence creates such as depression, anxiety, post-traumatic stress disorder, suicidality, and substance use disorder, therefore resources should be included for appropriate management. Anticipating the potential adverse outcomes aids the clinician to begin to formulate an appropriate discharge plan upon admission of the patient. Primary and tertiary education, which can be critical, can be provided at the bedside especially if that responsibility were delegated to the case management department. This process should be embedded in the electronic health record and discussed in huddles, team meetings, committee meetings, and in all-hands meetings. This message should be supported by leadership and echoed by the administration and staff. Health systems can also get involved at the primary education prevention level, for example, by sponsoring health fairs that disseminate vouchers for free summer camps or afterschool activities by notable celebrity personalities for school-age children and their parents. These gatherings can help inspire communities to set goals in order to keep individuals focused on positive environments. Additional educational platforms, panel discussions, and/or conferences that promote/teach how to begin and maintain healthy relationships could further be offered by healthcare facilities. To be effective with the community, the healthcare team must maintain safe and healthy work relationships themselves. It was found in a study of 18 healthcare providers in Brazil(who were interviewed to identify the existence of interpersonal violence among clinic staff) that they regularly witnessed violent acts while

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conducting home visits and that they themselves endured verbal assaults by clients who were themselves victims of sexual assault by a family member, thus resulting in behaviors by patients and staff uncharacteristic of their baseline behaviors (Florido et al. 2020). It was cautioned that if the providers personally lived in the same geographical area where interpersonal violence regularly occurs, they might themselves become immune to the incidences and thereby experience a reduction of empathy for their patients, resulting in employee burnout and clinical errors. In the following, we have included a range of perspectives on interpersonal violence, including several very intimate and personal experiences/stories. These perspectives are designed to illustrate that there is not a “one size fits all” approach to prevention or intervention to eliminate violence. This includes career steps that introduce the behavioral health provider to the world of policy and politics in order to learn how to bring about change on a larger scale. These stories show the very personal nature of violence and the need for community knowledge and cultural competence in addressing the potential domains and levels of influence placing communities at risk.

Personal Perspectives What follows is a series of personal perspectives on violence from different communities and individuals who have augmented their typical professional education to develop competency in the policy arena through fellowships and taken on leadership roles that involved advocacy essentially blossoming beyond the role for which they were trained. We hear from those in rural and indigenous American communities, from a mother and grandmother impacted by violence, and from those that engaged in intensive fellowships that changed their career trajectory. We see it as the way men are socialized and a need to change the basic foundation of our development as people. We also see the strategies and understanding needed and used in prisons, places defined by violence. Through the Lens of Rural America. Diana Shaw is Executive Director of the Lanai Community Health Center, a federally qualified health center, located on one of Hawaii’s smallest neighbor islands. She shares her perspective on violence in her rural and remote community of Lanai: Violence. . . we all like to think, “It will never happen here!” However, we live in very uncertain times. For many, stress is at an all-time high; stress is a partner of violence. So, how our friends, neighbors, and Ohana will react to situations is really not known. Our rural, remote community of Lanai is one where most residents know one another. They smile, wave to one another, and engage in casual conversations when they meet at the post office and store, or on the street. It is a nice community. Violence is an unusual occasion, and when it does occur, it is in the form of scuffles, sometimes with punches thrown (when too much drinking is involved). However, it is also a community where guns, bows and arrows, and knives are readily available. No, we are not an “open carry” community or state – however, we are a community where subsistence living is prevalent. Many in our community put food on their table

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by hunting the local mouflon sheep and axis deer, as well as diving for fish. Guns, bows and arrows, and knives are the tools of subsistence living. Often, hunting is a family occasion, with children learning to hunt quite young. So, is it wise to think “it will never happen here.” Can we blindly go about our business thinking bullying at school will stop short of violence? Or that the periodic scuffle will not escalate to a fight that uses subsistence tools as weapons? Or that a disgruntled patient will never become violent? Lanai Community Health Center (LCHC) has taken the approach that it is best to be prepared, and education is the method that we use. We start with our annual hazard vulnerability analysis. In 2019, our top five hazards included workplace violence: Hurricane (1), Cyber Attack (2), Inclement Weather (3), Workplace Violence/Threat (4), and Infectious Disease Outbreak (5). With this ranking, training comes in several forms. Recently, for example, several staff attended a police presentation on active attacker situations. They, in turn, presented the videos from the police training at our staff meeting. Annually, all staff also undergoes workplace emergency and workplace safety trainings. We do not stop there, though. Our approach is to look “upstream” – stress and stress management. We feel that we can decrease the chance of violence if we are able to identify those who might be exhibiting early signs of stress and tendency toward violence. Toward that end our staff is trained throughout the year in stress management – both at staff trainings and also through an online, on-demand training module. We also provide team exercises during staff meetings. Staff are also annually trained in detecting signs of sexual abuse, adult and child abuse. We have guest speakers who provide direction on their responsibility as a mandated reporter. In addition, remembering we are a very small community, staff are given additional advice and encouragement to report even when they might be reporting on a friend or relative – it is their duty and very likely could create greater harm if not addressed. Lastly, we work with the school educating the teachers and students on topics including cutting, suicide, and bullying. Recently, our community went through a really tough few weeks: within a day of each other, there was an unsuccessful suicide attempt and a successful suicide – not connected in any way. This situation was especially difficult, in that employees in our organization were directly connected to one or both of the victims. Staff were at a loss on what to say or do! Our behavioral health providers went to work, along with leadership, just being visible, consoling staff and offering support and comfort. Though feelings were too raw to do anything more at the time, we plan to follow up in a few months with more education and discussion in group staff meetings. But working with our staff is only part of the picture. We also try to proactively identify patients who are stressed and/or depressed. Every patient who is seen at LCHC (no matter which service: medical, dental, vision, behavioral health, etc.) is screened annually (more often for those who show signs of stress or depression) with a depression screening tool. It is unusual for this type of screening to be completed, say, for a dental visit – and initially, our dental assistants were uncomfortable using this screening tool. However, when the first dental patient was identified with severe

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depression and we were immediately able to get behavioral health support for that patient, both staff and dentists became believers in the process! Many speak of integrated services in health care. LCHC practices integration – but not just in the services we provide. We understand that integration extends to our staff, their friends, family and Ohana, our patients, and the community as a whole. We understand that education is a key to prevention – along with the ability to act and listen to one’s na’au. Violence can be minimized and maybe even prevented. Through the Lens of a Native American. Jacqueline Gray is a member of the Choctaw and Cherokee tribes and on the faculty of the University of North Dakota. She serves on the Health and Human Service national advisory boards, and she is a Fellow of the American Psychological Association. She shares her perspective on violence affecting Native American communities: violence in tribal communities – on August 19, 2017, 22-year-old Savanna Lafontaine-Greywind vanished from her apartment in Fargo, North Dakota. At the time, she was 8 months pregnant and was preparing to move into an apartment with her long-time boyfriend. Hours before her disappearance, she told family members she was going to help a neighbor, Brooke Crews, with a sewing project. Five days after her disappearance, Savanna’s baby was found alive in Crews’ apartment, and three days after that, her body was found wrapped in plastic in a nearby river. The following legal proceedings revealed that Savanna’s neighbor had brutally murdered her and stolen the infant. Although horrific in nature, Savanna was just one of the hundreds of Native American women who are reported missing each year. In fact, in some areas, Native women are up to ten times more likely to be murdered than the average citizen. Some of the data shows that American Indians/Alaskan Natives (AI/AN) are 2.5 times as likely to experience violent crimes as the general population of the USA. Four of five Native women have experienced violence in their lifetime. They are also twice as likely to experience rape or sexual assault than all other races. Overall, AI/AN women are more likely to be victims of violent crime than white non-Hispanic women. However, women are not the only targets of violence against Native Americans. AI/AN men report more physical and psychological violence from an intimate partner than white non-Hispanic males. The only areas where there are no differences are sexual violence and stalking which are not statistically different. These are usually under reported situations for males in general. Unlike other populations, AI/NA men and women are more likely to be victims of violence from interracial perpetrators than white non-Hispanic men and women. The reasons surrounding the high levels of violence against Native American women are rooted in a long and sordid history of the colonization of tribal communities. Yet, this was not always the case. Before colonization, many tribes, whether matrilineal or patrilineal, had leadership roles for both men and women. In some tribes, women had to vote to go to war before the men were allowed to fight. There was a very egalitarian (equal) approach to leadership. When European colonists came, they were appalled when women were present with leadership roles when they came to meet with settlers. Little known was that Native women were appalled that colonial women were not included in the meetings. Because of the power of Native

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women, colonial men moved to disenfranchise them of their power many times by sexual assault to demean them. During this time, American Natives were at particularly high risk for prostitution, rape, and physical and verbal abuse. Thus, was the beginning of violence against Native women in North America. The legislative history of Native Americans and the USA further complicates these issues. Before the 1990s, the Supreme Court weakened the ability for tribes to prosecute crimes by slowly and continuously reducing their jurisdictional authority. However, the 1994 Violence Against Women Act (VAWA) passed by Congress ensured that domestic violence would be considered as a crime, and later revisions incorporated funding specifically for minority populations. Nevertheless, Native American women were not allowed to file charges against non-native men on reservations until the VAWA reauthorization of 2013 and the Tribal Law and Order Act of 2010. Although legislation has been set forth to reduce the number of violent acts against Native Americans and to hold assailants accountable, continued efforts are necessary as evidenced by the case of Savanna Lafontaine-Greywind and so many others. An understanding of the unique politics surrounding Native American nations is needed to develop effective strategies to combat these acts of violence. Through the Lens of an Alaskan Native. Sandra Haldane is the former chief nurse of the Indian Health Service. She was a USPHS Congressional Fellow and is currently working as a school nurse in Anchorage. She is an Alaskan Native and brings a historical perspective to present-day violence among the indigenous people of Alaska and beyond: Perhaps no people in the country struggle to survive and thrive in two worlds more than American Indians and Alaska Natives. Since colonization, be it the lower 48 contiguous states or the 49th state Alaska, the indigenous people of this country have grappled for acceptance in a white-dominated society and endeavored to live some semblance of a life that sustained them for ions, when community, family, and all the land, sea, and air had to offer was all that was necessary. But with colonization came capitalism, a cash-based economy, and the utmost importance of individualism and not the whole of the community. Historical trauma endured by Native people led to psychic pain which has been exacerbated by the struggle to thrive in two worlds. The resulting outcome has been a mental health crisis with tragic consequences in many Alaska Native communities and families. Substance misuse and violence are rampant in our communities, and not only are the necessary mental health and social services unavailable, the psychic and spiritual healing that comes with a strong sense of belonging to a Native way of life is also often absent. Since Europeans arrived in North America, there has been an ongoing policy which has led to the wholesale removal of American Indians and Alaska Natives from their homelands. By the late 1700s, after diseases and epidemics, 1500 wars, attacks, and raids officially sanctioned by the US government, there were less than 300,000 Indians surviving. President Andrew Jackson summed up the federal government’s attitude toward Indians in his 1833 Address to Congress: “They have neither the intelligence, the industry, the moral habits, nor the desire of improvement which are essential to any favorable change in their condition.

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Established in the midst of another and a superior race. . . they must necessarily yield to the force of circumstances and ere [before] long disappear.” After 186 years, has this attitude changed? Think of what it means to a young American Indian or Alaska Native reading this history, full of like-minded statements. Think of the struggle of that youngster who is regaled with the traditions, pride, stories, and culture of these proud people he/she calls their own, yet they read, hear, and even see firsthand the oppression, decimation, and ongoing discounting, experienced by their people for the past 250 years. While Alaska’s history does not mirror that of any of the lower 48 Indian people, many of the policies and attitudes toward Alaska Native people are a carryover from those despicable times of colonization. • Prior to 1492, Indian children were educated within the family and community learning their language, survival skills, values, culture, and spirituality by observing, listening to stories, and being surrounded by everyone in the community. • From 1492 to 1775, the attitude of the colonies was to convert Indians to Christianity so they would become more white-like and civilized. The birth of trying to live in two worlds? • From 1776 to 1830, in an effort to protect land from European powers, make room for settlers, and squelch Indian wars, the US government signed hundreds of treaties with tribes, exchanging land, resources, and hunting and fishing rights for a promise of health and educational services. How well has that worked out? • From 1830 to 1880, Indians were removed from lands coveted by whites regardless of how much the tribes wanted to retain their ancestral homelands, a time when some of the greatest carnages were committed against American Indians: Trail of Tears, Mankato Executions, Sand Creek Massacre, Custer Campaign, Battle of Little Big Horn, and Wounded Knee. All of this took place less than 150 years ago. • 1880–1920 saw continued removal of Indians and their isolation on reservations, perhaps one of the most devastating times for Native people; when Indian children were sent to over 100 white-run boarding schools, now infamous for their atrocities, and subsequently the same happened in Alaska. By killing the Indianness in the child, the culture can also be killed, because the culture-bearers of any culture are their children. Removing a child from their parents’ love and guidance strips them of the opportunity to love and guide their own children in the future. • From 1945 to 1960 (recent history), several tribes were abolished and Indians were encouraged to move from reservations into cities. How well did this effort of assimilation work? Is it any wonder that Native people and communities are so traumatized? Is it any wonder why American Indians and Alaska Natives have difficulty trusting and believing in a government, and those who represent it? How many of our American Indians and young Alaska Natives question their self-worth and the value of their traditional culture when all they read about is what others have done to annihilate them?

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To reiterate, the Native worldview revolves around values related to family, community, spirituality, and the environment; concepts that often contrast with Western beliefs and practices. The federal government continued the Indian policy that would control nearly all aspects of Native life, including education, religion, medicine, law, subsistence, and land acquisition. The practice of sending indigenous children to boarding schools, separating them from their families and communities, enhanced a philosophy of assimilation by segregation and destruction of their culture. These policies and practices contributed and continue to contribute to the degradation of Alaska Native cultural strengths, languages, communities, and traditions that would otherwise enable them to lead meaningful, contributing, and satisfying lives. The cumulative emotional and psychological wounds inflicted upon Native Americans resulted in the most profound historical trauma that would pass from generation to subsequent generation. The effects of trauma on people because of their race, creed, and ethnicity linger on the souls of the generations who come after, resulting in higher rates of mental and physical illnesses, substance misuse, and erosion of families and community structure. Persistent cycles of trauma result in the destruction of families, communities, and the entire culture. Historical trauma is not only about what happened in the past, it is also about what continues today. Thus, we bear witness to the resulting disgraceful health disparities now experienced by our Native communities. Disparities such as these: • Suicide is the fourth leading cause of death, and alcohol abuse the seventh leading cause of death among Alaska Native adults. • Almost 40% of Alaska Native adults witnessed domestic violence as a child. • Alaska Native adults reported 3.6 days of poor mental health in a month, 20% higher than non-Alaska Natives. • 41% of Alaska Native adults report living among substance abuse in their household as a child, and 28% report four or more adverse childhood experiences. • 31% of Alaska Native adolescents experienced major depression in the previous year. • In 2015, almost one in seven (13.7%) Alaska Native high school students attempted suicide one or more times in the previous 12 months. • About 3.5% of Alaska Native women report the use of alcohol during pregnancy. • The prevalence of prenatal physical abuse among Alaska Native women is four times that of non-native women, and emotional abuse is 1.5 times higher. • High school completion among Alaska Native adults (more than 25 years old) is about 81% as compared to 93% for Alaska whites. • About 23% of Alaska Natives have a total family income that falls below the federal poverty level; one in four Alaska Native children lives in poverty. Where are the mental health and social services to meet the requisite needs of these people and communities? Indian Health Service is only funded at about 60% of need which then means that tribally operated healthcare facilities fare no better. Even with public and private third-party collections, Indian health programs are not able to recruit and retain adequate mental and behavioral health staff to some of the most

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rural and isolated places in the country. An unqualified example of the result of years of cultural degradation, the wholesale onslaught of assimilation ripping children from their families and parents is what we see in Alaska Native children being removed from their families and communities today. American Indian and Alaska Native children comprise the largest number of ethnic children in foster care homes in America, 13 of every 1000 children in 2012. Children in Alaska are twice as likely to be taken into foster care as children in the rest of the country. Twenty percent of Alaska’s children are Alaska Native, but they account for 65% of the children in foster care, thus seven percent more likely than white children to end up in foster homes. Maltreatment includes neglect, physical assault, mental injury, and sexual assault. Of the 920 statewide Alaska reports screened-in over the past 12 months, an average of 63% involved Native children. Over five years, the Alaska Office of Children’s Services reports that at any given time, an average of 3870 children are in “out-of-home” placement, removed from their family home due to unsafe conditions associated with maltreatment, 59% of whom were Alaska Native. For me personally, it is an uncomfortable push and pull to be content and proud of my Alaska Nativeness while trying to fit into a society where value is placed upon individual achievement and gain. I see daily the dominance of a culture that does not understand the Native way of being and does not appreciate the power and value of the people of this land who have survived and thrived for thousands of years. It is a constant struggle for us who are in the caring professions and are ourselves Alaska Native. The internal battle, the push and pull of two very different worlds, sometimes weighs heavily on my conscience, and the nagging question never stops: How to keep our people and our communities safe, healthy, and well? The challenges are overwhelming and sometimes paralyzing when one is trying to heal from 250 years of trauma. Through the Lens of a Prison Psychologist. Phil Magaletta is a psychologist who is a former career federal law enforcement officer for the Federal Bureau of Prisons. He brings a perspective to understanding the types of violence that may lead to incarceration and to the challenges of mitigating interpersonal violence within the close quarters of a correctional setting: When most people think of prisons and correctional psychology, they readily acknowledge the role of various therapies in challenging, correcting, and teaching skills to inmates who were, are, or can become interpersonally violent. Sentenced by a judge to serve a period of time, these are the men and women who required housing in a custodial environment. For some of these inmates interpersonal violence was instrumental – a means to an end, a method for achieving what they wanted. For others, it was expressive and potentially impulsive – an end in and of itself to express frustration or to gain power. To date, one can search and find various protocols that have supportive evidence for changing these violent propensities. In the correctional setting, nearly all violence is interpersonal, given the close quarters and compact housing arrangements. And, no one really questions that part of the responsibility of staff is to impact or support change processes with inmates. However, when one draws back even further and examines the staff in such facilities,

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and their perspective regarding violence, another perspective emerges. Day in and day out, law enforcement staff who work in correctional facilities gain daily practice mitigating and trying to reduce or prevent interpersonal violence for those they serve – the inmates who live daily lives during incarceration, and the public, who expect those inmates to stay behind the wall. This mission and juxtaposition provide a very unique perspective on violence and the strategies to mitigate it. Correctional staff, as law enforcement officers, are taught and trained from day one, in a model of response that avoids or reduces confrontation and provides a framework for a progressive use of force when necessary to achieve a zero-violence outcome. In fact, these officers are trained to keep the peace and reduce interpersonal violence. Although there may be tactical units also deployed during large-scale events, such as riots or hostage situations, the larger majority are trained to reduce violence through traditional application of active-listening and problem-solving skills. Across the nation, typically successful, and nearly every day invisible, corrections officers intervene to prevent and mitigate further escalation of interpersonal violence that stems from the inevitable disruptions that come from inmates living in close quarters, and which are accentuated when those who have lived criminal lifestyles characterized by low frustration tolerance, super optimistic “I can have whatever I want without working for it,” and other distorted cognitions. Holding and managing these approaches to emergent inmate crises, and potential critical incidents, as a way of living at work is sometimes difficult and often dangerous. Not without consequence, the impacts of being immersed in the context of violence can produce negative outcomes for the officer. Unfortunately, the rate of suicide among law enforcement personnel remains elevated. Even 25 years ago, we knew that twice as many police officers committed suicide as were killed in the line of duty. Thirty-five years ago, police suicide rates were three times that of a comparative population of municipal employees. And 45 years ago, police officers had the third highest percentage of suicides when compared to other occupational groups. However, except for police officers, the number of workplace nonfatal violent incidents is higher per 1000 employees for correctional officers than for any other profession, including taxi drivers, convenience store staff, mental health workers, and teachers. From 1992 to 1996, there were nearly 218 incidents for every 1000 correctional officers, for a total of 58,300 incidents. The reality of law enforcement stress, as well as the need for policies to mitigate and reduce the impact of this line of public service, is finally coming into its own. In 2018, The Law Enforcement Mental Health and Wellness Act was signed into law. This law will begin to shine a light on the practices and responses that offer departments the best chance at supporting their internal efforts at protecting and supporting the mental health of their employees. As part of this policy work, effectiveness of crisis lines, annual mental health checks for law enforcement officers, and the possible expansion of peer-mentoring programs will be made (https://cops.usdoj.gov/lemhwa). Through the Lens of Men. Ron Levant is a former president of the American Psychological Association and former dean of psychology at the University of Akron and Nova Southeastern University. He brings his professional focus on the

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psychology of men and masculinity to understand violence: The vast majority of sexual and gun violence crimes are committed by boys and men, yet most boys and men are not violent. An unpacking of this seeming paradox requires an analysis of the role of masculinity. Our new book (The Tough Standard: The Hard Truths about Masculinity and Violence) examines that question head-on, synthesizing over four decades of research in the psychology of men and masculinities, as well as popular accounts of recent events. Men are expected to be masculine, which usually means being self-sufficient, stoic, strong, dependable, brave, tough, a leader, hardworking, and avoiding conduct that is stereotypically feminine, such as emotional expressivity, empathy, and nurturance. However, few realize that these qualities (when taken to the extreme) can imprison some men, resulting in the constriction of their emotions, aggression, and violence. Further, even though most men are not violent, decades of research have shown that masculinity is related to sexual and gun violence and exacerbates working class men’s economic stagnation. To make matters worse, too many men are harmed by masculinity, suffering as a result of their adherence to masculine norms from poor physical health, shorter lives, depression, alexithymia, substance abuse, difficulty in recovering and growing from trauma, and, most tragically, suicide. Masculinity varies with other aspects of a person’s identity such as race/ethnicity, sexual orientation, gender identity, and age cohort, so that it is more appropriate these days to speak of masculinities. Girls and women benefited from many decades of conversations on how to navigate their gender in a changing world, and similar discussions are urgently needed for boys and men. New efforts to help boys and men find new ways to be in the world are necessary for both to address urgent social problems and to help the men themselves and their families (http://thetoughstandard.com). Through the Lens of a “Double” Congressional Fellow. Danny Wedding is a psychologist that was both a Robert Wood Johnson Health Policy Fellow and an APA Congressional Science Fellow. He is a former president of three APA divisions. He brings an appreciation of his fellowship experience, which enabled him to develop a perspective and understanding of policy and mental illness that changed his career and the lives of many he worked to serve: Looking back. . .. In 1988, I was an associate professor of psychiatry maintaining an active clinical practice and teaching medical students at the Marshall University School of Medicine. My department chair, a psychiatrist and an MD/JD, had been in the first class of Robert Wood Johnson (RWJ) Fellows, and he enthusiastically encouraged me to allow myself to be nominated for this program. Perhaps the most exciting thing about the program is that it is administered by the National Academy of Medicine (known as the Institute of Medicine when I participated), and most of the three-month orientation that precedes actual work on the Hill is conducted by members of the Academy, an exclusive and impressive group that includes some of the world’s leading scientists and health policy experts. Back then, RWJ selected five participates each year, and I was delighted to be chosen as one of the 12 finalists. The RWJ program flew each of us to DC for personal interviews. I still remember feeling that I must have been a “false positive”; this feeling was reinforced while I was waiting to be interviewed, and I learned that the man on my

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left was a neurosurgeon from Harvard, while the woman sitting on my right was a dermatologist from Yale. I had been raised on a chicken farm in Arkansas, and neither parent had graduated from high school! The interview went well, and it was clear that the individuals conducting the interview welcomed the opportunity to broaden the pool of Fellows by including someone in a medically related profession and from a small medical school devoted to training primary care providers for rural practice in Appalachia. Almost all previous Fellows had been physicians or advanced practice nurses; it was clearly time for them to open the door for a psychologist. I was selected as one of the five 1989–1990 Fellows. Being selected as the first psychologist to participate in the RWJ Health Policy Fellowship program was the highlight of my professional life. The three-month orientation (much of it held at the National Academies of Science Building on Constitution Avenue) was an amazing crash course in health policy. For example, the classes introducing us to the Medicare program were taught by Gail Wilensky – who was then running the Medicare program for President George Herbert Walker Bush. Our three-hour tour of the Health and Human Services (HHS) building was led by Louis Sullivan – who ran HHS! It was a heady experience, and it allowed us to meet and know almost everyone who was anyone in health policy in Washington, DC. Following the orientation, all Fellows interviewed for jobs on the Hill. Most of us wanted to work in the Senate, and I eventually wound up taking a job as a health policy legislative aide for Senator Tom Daschle who was then the junior Senator from South Dakota. Most of my time was devoted to reviewing legislation, sitting in on committee hearings, and meeting with hundreds of constituents who were concerned about one or another health care bill. Senator Daschle turned out to be a fortitudinous choice and a great boss. He was friendly, approachable, and deeply committed to reforming the health care system. His support for a single-payer system was profoundly important in shaping my own views and subsequent policy work. Traveling with Tom to South Dakota was the highlight of my RWJ year. Like many other politicians from rural states, he had a pilot’s license and flew his own small plane from one South Dakota town to another, holding town hall meetings in each place we visited. One of his visits to South Dakota was devoted to health care, and I got to write speeches and staff each visit to a hospital or health care setting. We shared numerous meals on this trip, and I got to visit Tom’s family home and meet his parents. I like to think Tom became more sensitive to mental health issues because I was on his staff. I am proud to have been the first psychologist selected for the RWJ Health Policy Fellowship program. Like so many others, I developed “Potomac Fever,” and I thought I would give up tenure and leave the academy forever. I had been accepted into the MPH program at Harvard, but I had also applied for and been accepted into the APA Congressional Science Program (administered by the American Political Science Association (APSA)). I decided to give up a full ride at Harvard to stay on the Hill; it was an intoxicating place to work, and I did not want to give it up. The APSA also conducted an orientation program, focused on science policy, and after this I interviewed again for Fellowship slots. I decided I needed to experience

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life on the House side. Although I received several Senate offers (Senators Kennedy and Rockefeller), after much deliberation, I opted to work for Congressman Conyers on the Government Operations Committee. Much of my time on Government Operations was devoted to preparing for hearings on health care reform. Congressman Conyers – who chaired the Congressional Black Caucus – was also a passionate advocate for single-payer health care reform. Several years after I left the Hill, I was asked by the American Association for the Advancement of Science (AAAS) to be part of a small group of advisors, all former Fellows, who were funded to travel to Australia to testify before the Australian Parliament regarding a bill that would set up and fund Parliamentary Science Fellows; the program was to be modeled after the Congressional Science program, and I was selected to represent the health policy area, largely on the basis of my participation in two separate Fellowship programs. It is not an overstatement to say that my time as an RWJ/APA Fellow changed my life. My former Dean – who had originally nominated me for the RWJ program – visited with me when he was in DC for a meeting of the American Association of Medical Colleges. He had become Dean of the medical school at the University of Missouri, and he wanted me to come run a health policy “think tank” called the Missouri Institute of Psychiatry. It was an offer I could not refuse, but I insisted on changing the name to the Missouri Institute of Mental Health (MIMH). I would run the institute for the next 20 years, working to improve the life of every Missouri citizen with a mental illness, addiction, or developmental disability. MIMH existed at the interface of the University of Missouri and the state department of mental health, and we brought hundreds of millions of grant dollars to the state. I simply would not have been able to assume the job without the rich educational and experiential opportunities made possible by the Robert Wood Johnson Foundation and the American Psychological Association, and I will always be grateful (Danny Wedding). Through the Lens of Another Congressional Fellow. Bob Frank was a Robert Wood Johnson Health Policy Fellow and served as president of the University of New Mexico. He is a former president of Division 22, Rehabilitation Psychology. He too, describes the impact of his fellowship on his career trajectory and encourages psychologists to gain policy experience and understanding to create change to serve the public good: Danny Wedding was the first psychologist to become a Robert Wood Johnson (RWJ) Health Policy Fellow, and I was the second psychologist to be chosen for the program. Like Danny, I had the opportunity to meet all the leaders in health policy in Washington through our orientation program. I worked for the junior Senator from New Mexico, Senator Jeff Bingaman, who sat on the Health, Education, Labor, and Pensions Committee (HELP Committee). The HELP Committee is one of the most influential Senate committees for health policy issues. After my year as an RWJ Fellow, Senator Bingaman asked my dean at the University of Missouri if I could continue to work on health issues for him. I spent several weeks each month in DC working on health issues while President Clinton was pushing for the passage of his reform bill. When I was back home in Missouri, I led Governor Mel Carnahan’s effort for state-based health reform.

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During the time spent in Washington and my time leading the Show Me Health Reform effort, I was struck by the absence of psychologists. Most proposed legislation did not include psychologists as healthcare providers. Psychologists did not lobby Senator Bingaman or anyone in his office. The years since those experiences, especially the last 2 years, have seen major improvements in psychologists telling their story on Capitol Hill. There is still room to improve our ability to tell our story to legislators and the public. Our education programs devote little time to professional identity or interprofessional activities. If our students could graduate with a basic understanding of health policy and advocacy, psychologists could make a much larger impact. Our colleagues in medicine, nursing, and dentistry do a better job creating a shared sense of identity as part of their education programs. Effective advocacy is more than knowing how to contact a Member of Congress and make a case for a particular issue. Effective advocacy includes understanding how policy is created and the pressure points within the system. A number of psychologists have served on the Hill. This is the most effective way to understand the broad landscape of how Washington works. As an example, those interested in having psychologists prescribe recognized that the typical advocacy approach would meet too much opposition. Recognizing that the chairman of the powerful Department of Defense Appropriations subcommittee should be their champion, they were successful in having him attach a provision to the department’s annual appropriations legislation requiring the establishment of a pilot program for prescribing psychologists. Doing this changed the vista of opportunities for psychologists. Unlike many psychologists, those involved retained their identity as psychologists even while serving as legislative staff. Through the Very Personal Lens of a Mother. Khalilah McCants is on the faculty of the Daniel K. Inouye Graduate School of Nursing, Uniformed Services University and provides her perspective on a mother’s responsibility to protect her child from interpersonal violence based on her experience with her school-aged daughter: For me the benefits of being a mother are realized when my children develop in accordance with the natural laws of human nature. In order to achieve important milestones in the lives of my children, my responsibilities, coupled with the responsibilities of society, must be fulfilled. One of these responsibilities is analogous to the police force motto “to serve and protect.” As a mother, the first step in protecting my children from interpersonal violence is to believe them when he/she shares with me what has/is happening to them. If I do not, it is unlikely that they will ever come to me or my husband for help again. Also, my reaction is influential in encouraging my children to open up and expound on the traumatic event. Hence, overreacting to what my child shares with me is a mistake. As parents, we tend to react based on emotion. This type of reaction is off-putting for my children and will cause them to be guarded. Hence, the best approach is for me and my husband to behave in a logical and calm manner as the storyteller unpacks the sequence of events. The second step in keeping my child safe from interpersonal violence is to document. It is important to document the time and day my child first shared the

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traumatic event. Moreover, I should keep track of the exact verbiage my child uses when sharing the details of the event(s). This type of documentation allows any lawmaker or official to adhere to the proper protocol that applies in the situation of interpersonal violence. In addition, the time and day that the information is first revealed are extremely significant as the clock begins to tick at that time and the statute of limitations starts from there. The statute of limitations is a time limit that whether or not the parents can proceed with a lawsuit, if appropriate. Maintaining open communication is the third step in the process of keeping my children safe. Communication with not only my child but engaging in rich discourse with administrators provides the opportunity to obtain clarification for all relevant parties about the traumatic event. I may find that violations of certain principles or laws are apparent. There are cases where adults make bad decisions because they are based on knee-jerk reactions. Consequently, these bad decisions have a negative consequence on the victim. Prudent decision-making and open dialogue give the wrongdoers an opportunity to apologize and right their wrongs. Many situations can be resolved without involving external parties through open and honest communication. The fourth step in the process of protecting my children is to seek guidance from a healthcare provider(s) immediately. Psychologists, nurses, etc., are invaluable as they are trained to help either the victim or the aggressor process and/or heal from the traumatic event and reduce the risk of recidivism. Depending on the severity, regular visits with the healthcare professional may be appropriate. A plan of care will be developed to meet the relevant party’s needs. The fifth and likely the most important action that I can take to protect my children is not to blame the child or spouse. Being mindful that it takes a huge amount of courage to admit to interpersonal violence, the child should continue to feel loved and supported. Also, awareness that opponents will insinuate that my child fabricated the story and these opponents will attempt to misrepresent my children are possible, if not probable. It is imperative that I toe the line in order to fight against the undermining behavior of an aggressor who does not want to be held accountable. What brought this home to me in a very personal manner – my daughter developed a friendship with another girl of the same age/grade/school/neighborhood. Due to maternal instinct and a strange gift to my daughter after a short period of developing this friendship, I became leery of the child and her parents. The mother of the other girl described the friendship of our children as a “hot and cold relationship.” She also attempted to invite my daughter swimming and to watch movies in their basement to which I repeatedly declined. One day the social worker at my daughter’s school called to report that the other child choked my daughter. My husband and I reported the traumatic event to the principal who arranged a meeting with me and the parents of the other child. In the meeting the father of the other girl revealed that our daughter was the topic of conversation in many of his daughter’s therapy sessions, which his daughter attended owing to her anger issues. The action taken at the end of the meeting with the principal was that our daughter would change classes, and moving forward, would not be placed in the same class with the

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other girl again. We also informed her parents that an extended break from the friendship between our daughter and their daughter would be appropriate. Through the Very Personal Lens of a Grandmother. Elizabeth Richeson is a private practice psychologist and Chair of the Advisory Board for Jennifer Ann’s Group advocating and educating to prevent dating violence in honor of her granddaughter Jennifer who was a victim of interpersonal violence. She collaborates with Beata Krembuszewski, a psychology graduate student at Sam Houston State University, to bring us her perspective on both the origins of mass shooting and violence as well as ways forward to change society: Little Bits of Paper. Where do you start when you feel as if your heart has been broken? I have called El Paso my home for more than 36 years and that August 3, 2019, shooting has destroyed the peace and serenity of the city. What makes the hardship more intense is knowing this story is way too common with a multitude of places suffering the same fate. As of this writing several years ago, there have been more than 2000 mass shootings since Sandy Hook in 2012 and 306 mass shootings in 2019 alone. The definition of “mass shooting” is not universally agreed upon. The definition used by the FBI is an act of violence committed with a firearm resulting in at least four deaths, not including the perpetrator, which occurs at the same time or over a relatively short period of time. The FBI regularly chronicles active shooter incidents, but because there is no set definition of a mass shooting, the data can appear different depending on the source. Mass shootings further fall into three categories: familicide mass shootings, felony-related mass shootings, and public mass shootings. Familicide shootings typically occur in a private residence, and most of the victims are members of the offender’s immediate or extended family. Felony-related mass shootings occur in the context of criminal activity, such as gang violence or robberies. Public mass shootings are shootings that occur in public areas, such as businesses, workplaces, or schools, and the shooting is not related to other criminal activity. Typologies of mass shooters have also been identified and can be split into three categories: the autogenic shooter, the victim-specific shooter, and the ideological shooter. The autogenic shooter is motiveless and attacks people due to disrupted internal processes. The victims of an autogenic shooter are often strangers, but they may be proxies symbolizing points of contention in the offender’s life. The victimspecific shooter is motivated by seeking revenge from one or more victims. This offender has clear targets in mind, but once the shooting occurs, they may target other, unknown victims. Lastly, the ideological shooter is motivated by political or racist beliefs and attacks individuals who oppose their views. Shootings noted took place primarily in venues in which the victims were not related to or known by the perpetrator. Interestingly, none of these account for “four or more” in the context of domestic violence. How many more incidents would there be if those were included? The typical archetype of a mass shooter includes a Caucasian male in his late teens to early 20s; he is autogenic and commits his crime in a public area. Recent research converges on offender gender, 96.1% of recent mass shooters have been male, but only 55.7% of them are Caucasian. Furthermore, 56.1% of recent mass shooters are categorized as being victim-specific and are motivated by revenge.

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Between 2009 and 2016, in about half of the mass shootings, the offender’s victims included a current or previous intimate partner or family member. The mass shooting in El Paso is now considered one of the most deadly public shootings in the USA. But there is another side of this issue that has too often been ignored. The mass shooting in El Paso is unique because the shooter was not motivated by revenge and the shooting had no relation to domestic violence or dating abuse. The shooter was motivated by racist ideologies, targeting Mexican individuals. The El Paso shooter’s motivation has been described as “hatred and bigotry,” and it aligns with white supremacist views. However, the other mostdeadly shootings were predominately committed by men whose history included domestic violence and/or dating abuse or rejections. Some have reported mass shootings as a mental health issue – or an issue related to violent video games. The USA has rates of mental health disorders equal to the rest of the world, but the percentage of Americans who are killed by guns is ten times higher than other advanced civilizations. Upon closer look, the relation between mental health and gun violence is not as strong as one might think. Between 2000 and 2015, only 42.9% of mass shooters were suspected of having a mental illness. However, impulsivity and anger issues do not warrant a mental health disorder. Regardless of the shooter’s categorization, i.e., ideological, victim specific, or autogenic, all mass shooters share an experienced grievance and are suffering from a mental health issue or some type of generalized strain. The difference among them is the target of their grievance; autogenic shooters experienced internal grievances, victim specific shooters experienced a grievance with a specific person, and ideological shooters experienced a grievance with a certain group. Likewise, violent video game releases, popularity, and internet searches for violent video games were not correlated with incidents of mass violence. While we can assume that there may be a peripheral issue of one or both of these, the predominant underpinning is pure aggression. These offenders are men (typically), ages 14–66, who are angry, and who have chosen to take out their aggression in the most egregious ways. Even though we don’t concern ourselves as readily with those individual murders by boyfriends, ex-boyfriends, husbands, and ex-husbands, crimes of domestic violence are still important. Scattered around my work station are little bits of paper with names of those victims, some of whose family members have contacted Jennifer Ann’s Group for help, our resources, or just for consolation. I don’t know how many little bits of paper I have collected in the 13 years I have worked on this issue, and I realize there is a part of me that does not want to know. I know there are too many. On February 15, 2006, my granddaughter was a murder victim at 18 when she was shot by an ex-boyfriend in Austin in 2006. The nonprofit Jennifer Ann’s Group is named after her and is run by her father who returned to school for a law degree to educate himself and be a better advocate regarding this issue. We believe that by educating our youth, we can create a future with a lower tolerance for abusive relationships, and in turn, fewer aggressors. We need to end the mass shootings where they start: at the roots of dating and domestic abuse. The use of video games, paradoxically, is one of our main “reach outs” to tweens, teens, and young adults. We discovered years ago that this is a preferred method of

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connecting with this group. With over 20 free-play educational video games covering a variety of topics that are hosted on our websites, we get more than 30,000 novel contacts per month from around the world. This year, we were chosen as finalists by Games for Change in New York in the category “Most Significant Impact” for our consent game Rispek Danis (Respect Dance) which was a transliteration of our consent game How to Blobbie Blobble. When we were contacted by Vanuatu, an island off the coast of New Zealand, to redesign our game to fit their cultural set, we were glad to do so. The game was translated to bislama, their native language, and the characters’ dress and environment set in Vanuatu settings. Additionally, one of our video games has been set up for a “walk through” experience in Adelaide, Australia at their MOD museum. While Jennifer Ann’s Group is a small organization, we have great knowledge and a big heart. As we work diligently to end dating abuse and its associated mass shootings, we must begin to resolve the myriad of causative factors that give rise to this unacceptable display of aggression. We want to see the decrease in mass shootings, regardless of the motivation, and we want to see it now. For more information and access to our free resources go to https://jenniferann.org/. We are particularly grateful that our colleagues in the Texas Psychological Association established their Jennifer Ann Crecente grant award for a Texas graduate student researching dating abuse/violence. Through the Lens of a Trauma Researcher. Terry Keane, president of the American Psychological Foundation and longtime director of the National Center for Posttraumatic Stress Disorder’s Behavioral Science Division, VA Boston Healthcare System shares the importance of funding research on prevention of violence: Preventing community violence and mitigating its psychological aftermath are funding priorities of the American Psychological Foundation (APF). In October 2019, APF centered its first ever fundraising Soiree in Washington, DC to raise financial support for young psychologists to study how and when to intervene to minimize interpersonal violent behavior and its traumatic impact. My role as director of the National Center for Posttraumatic Stress Disorder at VA Boston has brought home for me the importance of the APF Fund for Trauma Psychology, which includes the Christine Blasey Ford award, for supporting psychologists who study violence against women. That evening we raised more than $100,000 in support of these initiatives, but much more needs to be done to support this important work.

Effective Advocacy Individuals in the behavioral health and public health fields are genuinely motivated to help people (NASEM 2019b). The perspectives from this chapter illustrate both the varied types of violence and suggest methods required to stem violence tied to specific communities. In Lanai, there is integrated care that focuses on “upstream” stressors. Here, along with the violence against Native American women, we see the need for community expertise to understand what is stressing the community and what could empower the community and give it hope, thereby decreasing the

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likelihood of violent acts. The lens on masculinity suggests a socio-ecological reframe for men, perhaps particularly those from patriarchal cultures or from communities where men have little power due to unemployment, poverty, and loss of social stature. An analysis of what may be missing is well within the grasp of behavioral health providers, just as it was well within the grasp of our co-author who sought a solution within her daughter’s school for violent behavior. However, skills in advocating for individuals on a broader scale are generally lacking in graduate training. With the desire to help as a motivator for those who go into these fields, professionals should do well in taking the next steps to advocate for groups at risk for violence and can do so for a specific population or set of problems. The personalized stories illustrate the path of a Congressional Fellow and grieving family members who are thrust into circumstances that awaken them to a new way of looking at the problems facing society. Though behavioral health has long recognized the need and duty to share what we know to care for and protect society, we have fallen short of incorporating didactics or experiential training into our professions. There are several key areas of advocacy that are generally not taught, but could be, and with some tweaking, behavioral health providers should be more than prepared to advocate. The first key is realizing that providers can successfully engage in advocacy. The second is connecting with lawmakers and administrators. The third is realizing we owe it to our communities and to ourselves to take this next step and to teach our students to engage in advocacy. The fourth is having a vision for optimal policies and persevering toward those changes. Finally, teaching students to integrate empirical data into their cause in a way that is understandable to the community will strengthen their efforts. To all of these, we would add appreciating the importance of the media conveying your story. Acknowledging that advocacy is our responsibility takes most traditionally trained behavioral health providers, educators, and scientists way out of their comfort zone. However, with a little retooling in our vast tool sets, we can all do it. First, remember that lawmakers include local, state, and national representatives that work for you, the provider, educator, scientist, and the community you serve. Building relationships with lawmakers, administrators, and communities will aid in the progression toward positive change. Second, lawmakers and administrators make it their job to listen to and to be accessible to their constituents. Their job depends on it. An issue that is of critical importance to the community you serve will be of importance to them. There may be lawmakers and administrators that are already “on the job” addressing the community’s issues, or you may have to collaborate with your local community to “make the case” that this is important. Third, know your audience. The Lanai community assessment is an example of using data to document the community needs. Communities, legislators, and administrators alike can relate to a community needs assessment. Communication can be done in writing but ideally should include a visit to the lawmaker, the administrator, or their staff. Be prepared to use language and a way of thinking that fit their perspective. Emotional intelligence is also a necessity in effective communication. High emotional intelligence will enable health professionals to portray community

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needs with adequate self-awareness, self-regulation, self-motivation, empathy, and social skill. Communication should be succinct and clearly address how their constituents are impacted. And, as illustrated in the Congressional Fellow’s story, let us not forget the value of having behavioral health providers and legislators hearing directly from the community. This is why we strive to bring individuals underrepresented in our professions into the academy. It is not about proudly reporting that we have a diverse group of students we are preparing for practice, education, or science. It is about preparing community members to care for their communities and in the process learning from them as they improve our field’s cultural competency. Fourth, strong advocacy efforts begin with a vision of the desired community outcomes. With an ultimate goal in mind, we can create small steps directed toward policy change and violence prevention. Your vision may not already be supported directly by the literature. As long as change within the community is necessary, research may be conducted in response to community change. In the same vein, persistence is key as policy and community change take time and effort. Motivation, effective communication skills, and careful presentation of the research are only part of the battle. Please know that just because a convincing statement is made rejection can still occur. Health professionals, educators, and scientists should turn rejection into an opportunity to find an alternative. Lastly, realize that data are used for more than publishing papers in professional journals. Dissemination and implementation science have grown in the last decade; a step in the right direction by acknowledging research is not going to impact health by only being published in professional journals. But, we need to go further by beginning with the end in mind and using the research to aid policy change. What is the problem and what is needed to fix the problem? What data do we have to support what we need to do? For example, keeping in mind the historical context of Native Americans along with research regarding specific community stressors, what community-based efforts can be implemented to reduce violence against indigenous women? If you are intimidated, take a look over your shoulder and realize all you’ve accomplished to get to where you are. Believe you can do this (Sbrocco et al. in press). Start small, and it is likely that as you move through the system you will come to see that you can make a difference and find unexpected allies. And, you will come out the other end with a new skill set for helping people (NASEM in press). The alternative is simply unacceptable.

Concluding Reflections The immediate effects of violence are just the tip of the iceberg. Violence is often a symptom, an end point in a chain of circumstances, often multigenerational, designed to serve some function. Behavioral healthcare providers are well versed in the treatment of violence and in the understanding that violence is the product of social determinants. Providers also have a good understanding of the communities

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and cultures in which patterns of violence exist, of who is at risk, and why. Through science and practice we are able to recognize and understand violence. We are able to treat the individual and understand vulnerability at a community and individual level. We know the specific cultural groups, family dynamics, and neighborhoods that are vulnerable. This perspective is illustrated in the vignettes describing violence “Through the Lens” of individuals from different cultures and circumstances. With each of these stories and descriptions, the social determinants emerge. The next step is to take stories such as these and bridge the gap; to unite the stakeholders by increasing collaboration among the community, behavioral healthcare providers, and local public health officials; and then to impact local, state, and national legislation and policy. Providers are at the precipice of making this transition from service provision to legislation and policy. The evolution of behavioral healthcare into policy is natural and represents logical and necessary next steps. Professionals are well educated, and the science is commensurate with the practice; most would agree that the professions bear responsibility for taking the next logical step, partnering with communities and legislators and administrators to prevent violence. This bridge is already being built by curious and dedicated professionals who see this as the way forward, by professional organizations, by sponsorship of Congressional Fellowships, and by funding agencies that require dissemination and implementation plans. There is recognition that our professions need to include individuals from underrepresented communities in order to represent and tend to the needs of all of our citizens. Our next frontier is to require systematic education and training in policy in our professional requirements. We could then expect our next generation of behavioral healthcare practitioners to collaborate with legislators, administrators, the media, and policy makers to take the vast professional knowledge acquitted over the past decades and make major strides in violence prevention. All the pieces are in place.

Key Points • Interpersonal violence is an enduring issue in the USA and is overrepresented in many minority groups. • Each minority group has its own set of sociocultural issues leading to interpersonal violence. • The plight of these groups may be best articulated through the lens of the affected parties and allies. • Although much research has been produced to pinpoint causes and consequences of violence along with strategies for violence reduction, policy and community change are slow to take place due to the disconnect between behavioral health practitioners and policy makers. • Effective advocacy is necessary to bridge the gap between behavioral health practitioners, policy makers, and communities.

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• Effective advocacy is a necessary skill to teach future behavioral health practitioners, educators, and scientists; yet, it is generally lacking in current graduate training.

References Brotto, G. L. M., Sinnamon, G., & Petherick, W. (2017). Victimology and predicting victims of personal violence. In W. Petherick & G. Sinnamon (Eds.), The psychology of criminal and antisocial behavior: Victim and offender perspectives (pp. 79–144). San Diego: Elsevier Academic Press. DeLeon, P. H., & Kazdin, A. E. (2010). Public policy: Extending psychology’s contributions to national priorities. Rehabilitation Psychology, 55(3), 311–319. DeLeon, P. H., Sells, J. R., Cassidy, O., Waters, A. J., & Kasper, C. E. (2015). Health policy: Timely and interdisciplinary. Training and Education in Professional Psychology, 9(2), 121–127. Florido, H. G., Duarte, S. D. C., Floresta, W. M. C., Martins, A. M. D. F., Broca, P. V., & Moraes, J. R. M. D. (2020). Nurse’s management of workplace violence situations in the family health strategy. Texto & Contexto-Enfermagem, 29, e20180432. Heise, L. L. (1998). Violence against women: An integrated, ecological framework. Violence Against Women, 4(3), 262–290. Huecker, M. R., & Smock, W. (2020). Domestic violence. In StatPearls. Treasure Island: StatPearls Publishing. Humphreys, J., Sharps, P., & Campbell, J. (2005). What we know and what we still need to learn. Journal of Interpersonal Violence, 20, 182–187. Institute of Medicine (IOM). (2012). Health IT and patient safety: Building safer systems for better care. Washington, DC: The National Academy Press. https://doi.org/10.17226/13269. Institute of Medicine (IOM). (2015). Measuring the impact of interprofessional education on collaborative practice and patient outcomes. Washington, DC: The National Academies Press. Juarez, P. D. (2020). Screening for violent tendencies in adolescents. In V. Moelli (Ed.), Adolescent health screening: An update in the age of big data (pp. 115–134). Elsevier Academic Press. Kelly, S. (2014). Overview and summary: Societal violence: What is our response? The Online Journal of Issues in Nursing, 19(1). https://doi.org/10.3912/OJIN.Vol19No01ManOS. Overview & Summary. Kirschner, N. M. (2003). QMBs, SNFs and notch babies: A hippy banker tour. Presentation at the 111th a.P.A. Annual Convention. Toranto. Koss, M. P., & Gaines, J. A. (1993). The prediction of sexual aggression by alcohol use, athletic participation, and fraternity affiliation. Journal of Interpersonal Violence, 8(1), 94–108. McCants, K. M., Reid, K. B., Williams, I., Miller, D. E., Rubin, R., & Dutton, S. (2020). The impact of case management on reducing readmissions for patients diagnosed with heart failure and diabetes. Professional Case Management, 24(4), 177–193. Mercy, J. A., Hillis, S. D., Butchart, M. A., Bellis, M. A., Ward, C. L., Fang, X., & Rosenberg, M. L. (2017). Interpersonal violence: Global impact and paths to prevention. In C. N. Mock, R. Nugart, O. Kobusingye, & K. R. Smith (Eds.), Injury prevention and environmental health (3rd ed.). Washington, DC: The World Bank. Moreno, L. A., Borraez, O., & Ulloa, J. H. (2016). Vascular trauma in Latin America. In T. E. Rasmussen, H. B. Shumaker, & N. R. M. Tai (Eds.), Rich’s vascular trauma (3rd ed., pp. 329–332). Philadelphia: Elsevier Academic Press. National Academies of Sciences, Engineering, and Medicine (NASEM). (2019a). Proceedings of a workshop on achieving behavioral health equity for children, families, and communities. Washington, DC: The National Academies Press.

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National Academies of Sciences, Engineering, and Medicine (NASEM). (2019b). Taking action against clinician burnout: A systems approach to professional Well-being. Washington, DC: The National Academies Press. National Academies of Sciences, Engineering, and Medicine (NASEM). (2019c). Vibrant and healthy kids: Aligning science, practice, and policy to advance health equity. Washington, DC: The National Academies Press. (in press). Proceedings of a workshop on key policy challenges and opportunities to improve care for people with mental health and substance use disorders. Washington, DC: National Academies of Sciences, Engineering, and Medicine (NASEM), The National Academies Press. Niolon, P. H., Kearns, M., Dills, J., Rambo, K., Irving, S., Armstead, T., & Gilbert, L. (2017). Preventing intimate partner violence across the lifespan: A technical package of programs, policies, and practices. Atlanta: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Perez-Stable, E. J., & Collins, F. S. (2019). Science visioning in minority health and health disparities. American Journal of Public Health, 109(S1), S5. https://doi.org/10.2105/ AJPH.2019.304962. Ramaswamy, A., Ranji, U., & Salganicoff, A. (November, 2019). Intimate partner violence (IPV) screening and counseling Services in Clinical Settings. Kaiser Family Foundation Issue Brief, 1–2. Sammons, M. T., & VandenBos, G. R. (2019). Making research pertinent to clinicians’ needs. The Journal of Health Service Psychology, 1–3. https://doi.org/10.1007/s42843-019-00002-0. Sbrocco, T. S., Vaughan, C. L., & DeLeon, P. H. (in press). A bridge to better care. Clinical Psychology: Science and Practice. Schimmels, J., DeLeon, P. H., Hively, J., Arias-Reynoso, M., & Wilkniss, S. M. (in press). The political process – Critically important for behavioral health. In C. Frisby, W. O’Donohue, & S. O. Lilienfeld (Eds.), Psychology and politics. Hoboken, Springer. Vieth, V. I., Goulet, B., Knox, M., Parker, J., Johnson, L. B., Tye, K. S., & Cross, T. P. (2019). Child advocacy studies (CAST): A national movement to improve the undergraduate and graduate training of child protection professionals. Mitchell Hamline Law Review, 45(4). https://open. mitchellhamline.edu/mhlr/vol45/iss4/5. Waters, H., Hyder, A., Rajkotia, Y., Basu, S., Rehwinkel, J. A., & Butchart, A. (2004). The economic dimensions of interpersonal violence. Geneva: Department of Injuries and Violence Prevention. The World Health Organization. World Health Organization (WHO). (2014). Violence and injury prevention: Global dtatus on violence prevention 2014. https://www.who.int/violence_injury_prevention/violence/status_ report/2014/en/.

Future Directions in Interpersonal Violence and Abuse Interventions Across the Lifespan

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Michael Levittan, Nada Yorke, Mary Beth Quaranta Morrissey, Thomas Caprio, and Patricia Brownell

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Historical and Current Neglect of Child Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Public Health Issue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Secondary Intervention and Adverse Childhood Experiences Research . . . . . . . . . . . . . . . . . . Trauma-Based Treatment for Child Victims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Parental Enhancement Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tertiary Intervention with Offending Parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hotline for Good Parenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rethinking Childhood Diagnoses as Family Systems Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “Failure to Be Present” as Child Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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M. Levittan (*) UCLA Extension, Los Angeles, CA, USA N. Yorke Yorke Consulting, Sequim, WA, USA M. B. Q. Morrissey Global Health Care Innovation Management Center, Fordham University, New York, NY, USA Global Healthcare Innovation Management Center, Fordham University Gabelli School of Business, West Harrison, NY, USA e-mail: [email protected] T. Caprio Finger Lakes Geriatric Education Center, University of Rochester Medical Center, Rochester, NY, USA e-mail: [email protected] P. Brownell Graduate School of Social Service, Fordham University, New York, NY, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_96

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Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Research on Batterer Intervention Programs (BIPs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Measuring Effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Future BIP Designs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Systemic Interventions for Offenders and Victims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sexual Abuse and Rape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mass Public Campaign to Dismantle Rape Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Address Barriers to Reporting Sexual Assault . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trauma-Informed Intervention for Victims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Changes to the Criminal Justice System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bring Men Along . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intervention for Offenders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Actions That Can Be Implemented Now . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Abuse of Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Polyvictimization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Interpersonal violence intervention is an issue of immediate and critical concern. Throughout this handbook various forms of interpersonal violence across the lifespan are discussed and evaluated, with current strategies and interventions. The field of intervention regarding various forms of abuse involving children and older adults, sexual assault, and domestic violence has already made significant advances. To date, increasing attention, both public and professional, has been given to these areas of victimization, in terms of assessment tools, and treatment approaches using evidence-based and trauma-informed strategies, but much more can be done to eliminate this epidemic of violence in our society. In addition to the immediate impact of physical harm, interpersonal violence results in long-term psychological damage to not only the individual victim but to families and society at large. Therefore, it is incumbent on those working in the field to conduct assessments of treatment programs and evaluate current research to create more effective treatment protocols along with evidence-based implementations. This chapter focuses on future interventions covering both victims and perpetrators, as well as systemic issues that are central to research, practice, policy, and advocacy. In order to be effective, interventions and research must be equipped to meet the formidable challenges posed by the complexity, persistence, and traumatic effects of interpersonal violence as a social, cultural, and intergenerational problem affecting diverse populations and communities. Keywords

Child abuse · Batterer intervention · Neglect · Positive parenting · Elder abuse · Rape · Sexual assault · Partner violence · Secondary intervention/prevention · Tertiary intervention/prevention · Public health

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Introduction To gain a thorough understanding of the future directions of any social progress movement in the advancement of civilized societies, it is necessary to consider historical context. When contemplating the advances of interpersonal violence prevention from days of antiquity to the present day, the magnitude of change, with the accompanying transformation of consciousness in the human species, is immense. Simply put, in a little more than a century, most Western cultures have moved from the position of women and children as outright property of males to the position of women and children having legal protections and equal rights to males (in theory, if not in practice). Institutionalized racism and sexism throughout our systems involved in the care of victims and offenders continue to perpetuate interpersonal violence and abuse, however. By gaining a comprehensive overview of how far we have come in preventing interpersonal violence, we can begin to specify some of the steps that must be taken going forward in order to advance both the protocols of treatment and intervention. Where applicable, primary, secondary, and tertiary prevention and intervention strategies are discussed. Primary refers to interventions intended to prevent the onset of abuse, such as programs that educate the public about healthy vs. unhealthy behaviors. Secondary prevention programs target individuals at high risk for involvement in abusive relationships, while tertiary intervention is meant to eliminate abuse and reduce recidivism in families where abuse has already occurred in order to help them recover from the trauma. Many organizations in our society share the goal of eliminating interpersonal violence. The goal of elimination certainly seems daunting, but is nonetheless feasible. Practitioners and researchers are engaged separately or collectively in seeking to identify more effective interventions to eliminate interpersonal violence. This Future Directions chapter focuses on four aspects of interpersonal violence: child abuse; domestic violence (also referred to as “intimate partner violence,” or IPV); sex abuse/rape; and elder abuse. Ideas presented in this chapter are based in both practicality and possibility, some feasible, some thought-provoking, and some that require transcending past current limits. Hopefully, readers will have opportunities to develop their own methods of intervention based on theoretical or research frameworks and promote the ongoing collaborations to further the cause of ending violence and abuse across the lifespan.

Child Abuse Historical and Current Neglect of Child Abuse Throughout history, children have endured such barbaric practices as infanticide (Levittan 2012), abandonment, sacrifice, internment, pedophilia, incest, prostitution, severe labor conditions, harsh physical punishments, as well as the belief by some that children are born in sin. Ultimately, it was the drive to protect the young that

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attained enough hegemony that brought about sympathy for innocent, vulnerable, and helpless children. The first vulnerable, helpless creatures that motivated humans to create organizations and protections sanctioned by society were dogs and cats. When social worker Mrs. Wheeler in 1871 was unable to get help from police or government to intervene with Maryellen, an abused 6-year-old girl, she turned to the American Society for the Protection of Animals (ASPA). President Henry Berg immediately responded by bringing the case to court. Shortly thereafter the organization broadened its scope to become the American Society for the Protection of Children and Animals (ASPCA). There has been substantial growth by childcentered agencies, both governmental and public-funded, to further the cause to protect children, yet failures to protect are too commonplace in current society. Incidence, prevalence, and immediate and long-term consequences demand that child abuse be treated as a serious public health issue (▶ Chap. 50, “Implications of Maltreatment for Young Children”; Merrick and Latzman 2014). Over 37% of US children and 53% of African American children are investigated by Child Protective Services (CPS) by the age of 18 (Hyunil et al. 2017). On January 28, 2019, the U.S. Department of Health and Human Services, Children’s Bureau (2019) published the 28th edition of the Child Maltreatment Report, revealing that in 2017, 3.5 million children were subjects of investigation, with an estimated 674,000 cases substantiated. Approximately 1,720 children died from abuse and neglect in 2017. Of the three reportable types of child abuse, 74.9% of victims suffered neglect, 18.3% were physically abused, and 8.6% sexually abused (2017). It is noteworthy that incidence of child maltreatment is even greater when tabulated by the child’s self-report, with rates of abuse and neglect highest among infants and young children. With broad education of the general public, the probability of protecting the most vulnerable children is increased. The lack of public awareness is reflected in a US survey that 54% of African Americans, 51% of Hispanics, 43% of non-Hispanic whites, and 34% of Asians personally consider child abuse and neglect a “serious problem,” but they do not believe others have the same opinion (Research America, 2018; https://www.researchamerica. org/sites/default/files/ChildAbuseandNeglectPressReleaseDeckJune2018FINAL3.pdf). Across diverse populations, there is wide support for the idea that further research is needed on a governmental level to better understand, prevent, and treat child abuse and neglect.

Public Health Issue The natural place to begin the work of intervention and elimination of child abuse is with the education of parents and/or caretakers with a broad public awareness campaign so that some of the responsibility for protecting children shifts from parents per se to society at large (▶ Chap. 2, “Integration of the Types of Interpersonal Violence Across the Lifespan”). Parents are situated within a wider societal context. With greater public awareness, parents may well feel as if they are no longer parenting with total impunity. Accountability to society could put a check on parental abuses.

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Messages of positive parenting must be widely disseminated among all members of society. Positive parenting may be described as caring, guiding, nurturing, teaching, empowering, and setting boundaries with children according to their developmental stage, and within an overall context of unconditional love. The sensitivity involved may be best exemplified in terms of discipline. Generationally habitual behaviors such as scolding and punishing can be transformed into interactive parent-child moments of understanding and teaching (▶ Chap. 15, “Corporal Punishment: From Ancient History to Global Progress”). Currently, there exists a glaring dearth of positive parenting information for the general public. This needs to be corrected.

Secondary Intervention and Adverse Childhood Experiences Research The Adverse Childhood Experiences (ACE) research (Felitti et al. 2019; ▶ Chap. 5, “Adverse Childhood Experiences: Past, Present, and Future”) revealed that abuse endured in childhood has a cumulative impact on an adult’s health status (also see ▶ Chap. 176, “Impact of Childhood Maltreatment and Polyvictimization on Adult Revictimization”). Studies found that children exposed to domestic violence are at significantly increased risk of experiencing other forms of abuse and maltreatment (English et al. 2009). Additional research confirms that offenders who commit domestic violence have higher ACE scores (▶ Chap. 102, “Intergenerational Transmission of Intimate Partner Violence: Summary and Current Research on Processes of Transmission”; Hilton et al. 2019). The ACE findings can be employed as a secondary means of intervention in potential child abuse cases. Screening methods to identify children at risk, such as the ACE questionnaire, must be designed to be noninvasive, non-stigmatizing, and easily accessible in order to minimize defensiveness and encourage self-help in families. Once identified, services that may be provided to these families include early social support services and parent education focused on developmental needs of children (Thyen 2010). Additionally, respite programs are available to provide temporary relief to parents going through a family crisis or those with special needs children.

Trauma-Based Treatment for Child Victims Currently, there exist several models for treatment of traumatized children (▶ Chaps. 176, “Impact of Childhood Maltreatment and Polyvictimization on Adult Revictimization,” and ▶ 49, “Correlations Among Childhood Abuse and Family Violence, Prevention, Assessment, and Treatment from a TraumaFocused Perspective”). These tertiary interventions basically represent different forms of exposure therapy. What differentiates these approaches are the methods employed to narrate the traumatic memory and the distractions used to

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supplement necessary psychological defenses that are meant to prevent re-traumatization. Examples of treatment models are Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Narrative Exposure Therapy, Eye Movement Desensitization & Reprocessing (EMDR), Traumatic Incident Reduction (TIR), Progressive Counting, and Structured Play Therapy, each of which is supported by well-documented evidence (▶ Chap. 69, “Mental Health and Healthcare System Responses to Adolescent Maltreatment”). A promising approach to increase the availability and accessibility of these treatments is the CommunityBased Learning Collaborative (Hanson et al. 2019). This recently developed approach seeks to foster collaboration among multiple service agencies, both professional and nonprofessional, in order to provide parents, clinicians, and child protective services with necessary information to facilitate the implementation of appropriate care for traumatized children.

Parental Enhancement Programs Currently, there exist programs and services, in-person and online, for parents to improve their knowledge and skills at parenting (▶ Chap. 14, “Parents Who Physically Abuse: Current Status and Future Directions”). The Triple P/Positive Parenting Program (https://www.triplep.net/glo-en/find-out-about-triple-p/), developed in Australia in 1996, has been used in over 25 countries. It is a form of secondary intervention providing parents with simple practical strategies and tools to promote healthy relationships within the family, provide management strategies for behavioral issues, and prevent problems before they arise. The Triple P program is evidence-based with definite benefits, but due to the great variety of populations that it serves, research as to its effectiveness must be ongoing (Sanders et al. 2002). The Violence Prevention Office of the American Psychological Association implemented ACT (Adults and Children Together)/Raising Safe Kids (https:// www.apa.org/act/) in 2001. This intervention program is based on research showing that early years are critical for a child’s development and that ACEs have long-term effects on cognition, behavior, and brain development. The purpose of ACT is to teach both parents and caregivers positive parenting practices and skills to protect children from abuse and neglect. In 2017, the APA reported the effectiveness of the program, according to the Head Start Office of US Department of Health and Human Services, the World Health Organization, and California Evidence-Base Clearinghouse (https://www.apa.org/act/about/). Typical areas of focus include basic child-rearing, developmental stages, discipline, self-control, compassion, and types of child abuse. First 5 California (2020) was initiated when research revealed that critical brain growth and other developmental milestones take place during the earliest years of a child’s life. Child development was deemed a priority, and so programs were initiated in California for children (prenatal through age 5) and families to assist with education, health services, and childcare. Goals are focused on increasing positive outcomes for young children. Promotion of these services to the

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public is needed, as currently these programs are most frequently utilized by parents referred or mandated by CPS agencies or Family Courts. Dissemination of information can be viewed as a foundation for intervention and prevention of child abuse. Education about healthy, positive parenting needs to be provided prior to becoming a parent. Currently, no classes exist which serve as prerequisites for parenting a child. High school parenting courses can be created in the context of relevant issues that frequently arise between students and their parents. Another solution for prospective parents may be to offer incentives to obtain instruction on various topics, such as stages of child development, building children’s self-esteem, and compassionate discipline. It is crucial to the well-being of children and ultimately the well-being of society that there be a widespread movement to educate the public on principles and guidelines of positive parenting. A campaign, coordinated with federal and state governments and local communities, would target social media, public service announcements, billboards, newspaper and magazine coverage, high school and college courses, television, radio, and Internet programming that exhibit examples of good parenting. Hopefully, positive parenting principles will become ubiquitous in society and foster reductions in the intergenerational transmission of child abuse (▶ Chap. 102, “Intergenerational Transmission of Intimate Partner Violence: Summary and Current Research on Processes of Transmission”).

Tertiary Intervention with Offending Parents Though there exists research literature and websites with detailed lists of risk factors for parental abuse of children, there remains a dearth of information on protective factors and treatment methods to work with offending parents (▶ Chap. 14, “Parents Who Physically Abuse: Current Status and Future Directions”). A review of the literature indicates mixed results for most programs studied (Vlahovicova et al. 2017). Essentially, most programs can be classified as behavioral training for parents for the purpose of preventing the recurrence of child physical abuse. Two practices that can serve as effective templates for all interventions, prevention, secondary, or tertiary are psychoeducation and parental support. Tertiary intervention in child abuse cases focuses on families when abuse has already been reported. When working with maltreating parents, it is clear that effective interventions must go beyond teaching positive parenting skills and directly address issues of abuse and neglect (Whitcomb-Dobbs and Tarren-Sweeney 2019). A long-standing tertiary intervention program is Parents as Teachers (https:// parentsasteachers.org/), which began as a home-visiting pilot project in 1981, for the purpose of promoting and helping parents embrace their role as their child’s “first and best teacher.” The program, now employed in several states in the United States, focuses on developing customized curricula that support parents to foster healthy development of children, as well as school readiness. The home-visiting component

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of the program comprises personal visits, child screening, group connections, and resource networks. In a recent study of its effectiveness as a secondary intervention program, it was found that families with prior engagement with CPS had significantly reduced recidivism with these agencies (Johnson-Reid et al. 2018). Parenting Inside-Out (http://www.parentinginsideout.org/) is an evidence-based parent training program for families involved in the criminal justice system. It is primarily intended for incarcerated parents, as well as those on probation or parole. The primary goals are to eliminate criminal behaviors, reduce recidivism, improve family relationships, and facilitate child visitation. The Oregon Social Learning Center (2014) conducted a longitudinal study confirming reduced recidivism, improved parental participation, and reduction of substance abuse for participants in this program (https://www.oslc.org/projects/parenting-inside/). Three of the more effective programs include SafeCare (https://safecare. publichealth.gsu.edu/), Parent-Child Interaction Therapy (PCIT) (https://pcit.org), and Alternatives for Families – CBT (https://learn.nctsn.org/course/index.php? categoryid¼70). SafeCare, founded in 2007, makes use of social learning theory to focus on children’s safety, parent-child interactions, and specifically targets parents who have perpetrated neglect and physical abuse. PCIT employs a coaching approach to parents of children with behavioral problems, emphasizing warmth in the relationship and calmly managing challenging situations. AF-CBT is an evidence-based, trauma-informed out-patient treatment model. The immediate goal is to improve parent-child relationships in families where frequent conflict, physical discipline, and physical abuse are occurring. There is often a fine line between physical abuse and corporal punishment. The abusive parent or parent with long-held beliefs in the “spare the rod” philosophy of child-rearing can try to justify physical abusive acts as a form of child discipline. Durrant ▶ Chap. 15, “Corporal Punishment: From Ancient History to Global Progress” suggests that corporal punishment is motivated by parental attempts to control or deter behaviors when they perceive an affront to their authority; it can also be an impulsive reaction to stress, frustration, or anger. The parenting programs mentioned above, along with broad public education, and legal prohibition are viewed as most effective means of eliminating corporal punishment. There exists a Global Initiative to End All Corporal Punishment of Children (https://endcorporalpunishment.org/), which employs the more real and powerful phrase, “legalized violence of children” to enact universal prohibition of the practice. As of March 2020, 60 nations, following Sweden’s lead in 1979 (▶ Chap. 23, “Corporal Punishment: Finding Effective Interventions”), have outlawed all forms of corporal punishment. The United States is not among them. Research is genuinely needed in order to assess long-term effectiveness of current programs and additionally, to determine correlations between physical abuse of children and environmental conditions, including employment, poverty, substance abuse, and domestic violence. It appears that the effectiveness of programs geared to prevent further abuse of children needs to involve treatment that takes into account specific character traits of each parent.

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Hotline for Good Parenting There is a national hotline for reporting child abuse and the website for reporting it (www.childhelp.org/hotline/). As part of the nationwide campaign to promote positive parenting, there needs to be 24/7 hotlines that educate people about healthy parenting techniques, as well as help to problem-solve difficult parentchild interactions. Parents would be able to contact counselors over the phone or Internet with situations and questions, while in the midst of a difficult interaction with their child. A “Good Parenting Hotline” would serve as an essential component of the public awareness campaign. With broad-based marketing strategies, including ease of access to the hotline, the topic of good parenting can become pervasive in our society, thereby destigmatizing the idea of needing help with one’s parenting.

Rethinking Childhood Diagnoses as Family Systems Issues Diagnosing can be viewed as an authoritative way of affixing a label to a child. The more foundational problem may be the interpersonal violence occurring in the family. The genesis of childhood diagnoses is often rooted in a child’s problematic behavior or lack of compliance as identified by parents, teachers, and other caretakers. The family systems concept of “identified patient” is at play, with subsequent focus of family problems placed squarely on the child (the “problem child”) for intervention. Concomitantly, environmental factors, such as violence in the home, parental psychological disorders, poor living conditions, and/or lack of stability in the family are overlooked (▶ Chap. 46, “Psychological Maltreatment of Children and Youth: A Historical Perspective on the Right to Be Emotionally Safe”). The real purpose of the diagnosis or problem child label may be to serve as convenient way that parents use to avoid family or other interventions for various family dysfunctions as the possible roots of the child’s identified behaviors. Interventions must go beyond the specific label or diagnosis, and screen for child abuse and domestic violence in the family, which serves to highlight the harm caused to, and not by, children (▶ Chap. 49, “Correlations Among Childhood Abuse and Family Violence, Prevention, Assessment, and Treatment from a Trauma-Focused Perspective”; Franshek, et al., 2017). Numerous studies show that domestic violence affects children psychologically (anxiety, depression, attachment disorders, dissociative symptoms) and behaviorally (noncompliance, aggression, delinquency), and this is where intervention and treatment are needed (Kimball 2015; U.S. Department of Health and Human Services, Office of Women’s Health 2019). Further research is needed to determine the efficacy of a family systems approach and the influence of environmental factors on child development so as not to prematurely diagnose and label a child which may hinder appropriate interventions.

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“Failure to Be Present” as Child Neglect The Centers for Disease Control and Prevention (CDC) lists four types of child abuse: physical, sexual, emotional, and neglect, with neglect being the most commonly reported and substantiated type (https://www.cdc.gov/injury/features/pre vent-child-abuse/index.html, 2020). Approximately 75–80% of reports fall under the category of neglect (American Society for the Positive Care of Children, 2018; CDC, 2014; U.S. Department of Health and Human Services, 2017). The two recognized types of neglect are “Failure to Provide” and “Failure to Supervise,” which cover the neglect of basic needs and safety of the child (▶ Chaps. 26, “The Etiology of Child Neglect and a Guide to Addressing the Problem,” and ▶ 27, “The Nature of Neglect and Its Consequences”). Similar to but more comprehensive than what Garbarino (▶ Chap. 46, “Psychological Maltreatment of Children and Youth: A Historical Perspective on the Right to Be Emotionally Safe”) calls, “ignoring,” a third category of child neglect, “Failure to be Present,” may be defined as consistent failure of a caretaker to provide a full, intimate experience when spending time with their child. Two very early and significant aspects of being present are maternal eye gaze and parental sensitivity (Bedford et al. 2017). It seems logical to assume that eye gazing and sensitivity continue to be important components of a parent’s repertoire for their offspring, beyond infancy and throughout childhood. In current society, failure to be present would not be a reportable offense, due to difficulties in assessment and commonality of practice. However, the crucial nature of being present for children must be included in primers of good parenting. Quality of time spent with children is believed to be even more important than quantity of time spent (Milke et al. 2015). A recent study in Denmark attested to the positive correlation between time spent with children and positive cognitive development, child behavior, and school grades (Falleson and Gahler 2019). The study addressed the quality of time spent, prioritizing developmental activities (talking, playing, teaching, and reading) over non-developmental activities (care and management). The full presence and availability of parents to inquire, listen, and respond to their children’s thoughts, feelings, stories, and questions are critical engaging meaningfully with their children. Anyone who has been a parent knows that the time of parenting your child goes by quickly. Opportunities for child and parent to “be together” in present-time moments are all too fleeting.

Intimate Partner Violence The complete eradication of IPV may not be achievable, but significant reductions are certainly a possibility. According to the Bureau of Justice Statistics (2012), the overall rate of IPV declined approximately 64% over an 18-year data collection period (1993–2010). This section will focus on offender interventions that offer the possibility of reducing the incidences of IPV and thereby the rates of victimization, and the negative effects of children’s exposure. Fortunately, there are programs and

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interventions that appear to have some success in reducing the rates and severity of IPV offending, but there is much room for improvement with fresh innovative ideas. Breaking the intergenerational cycle of IPV will require research-informed efforts that utilize not only current primary prevention efforts but also all available secondary and tertiary intervention strategies (▶ Chaps. 99, “Intimate Partner Violence Across the Lifespan: Dyadic Theory and Risk and Protective Factors,” and ▶ 102, “Intergenerational Transmission of Intimate Partner Violence: Summary and Current Research on Processes of Transmission”). Primary prevention efforts that seek to reach persons before there is a first-time experience of victimization or perpetration are the ideal. However, secondary prevention efforts can reach those who have experienced victimization and seek to stop the cycle of violence through education or cognitive restructuring, such as current teen dating violence programs for those who have already been exposed to IPV in their families of origin (▶ Chap. 112, “Best Available Evidence for Preventing Intimate Partner Violence Across the Life Span”). Tertiary intervention programs are directed at those persons who have been victimized or perpetrated violence, and these efforts are seeking to prevent further violence from occurring. One example of tertiary efforts is primarily demonstrated through batterer intervention programs (BIPs) which are currently used in most states and many countries outside the United States. These programs are usually ordered by criminal courts or child protective service agencies as a response to domestic violence arrests and/or convictions. In the United States, the first programs began emerging in the 1970s. Tertiary prevention efforts can also be implemented beyond current community batterer intervention programs by reaching out to inmates in jails and prisons who may not have formal arrest records for domestic violence, but may well struggle to experience healthy, nonviolent relationships (Yorke et al. 2010).

Research on Batterer Intervention Programs (BIPs) Programs for perpetrators of IPV are often described as “interventions” or “treatment,” and more recently as Relationship Violence Intervention Programs (RVIPs), which are seen as less stigmatizing (▶ Chap. 138, “Relationship Violence Perpetrator Intervention Programs: History and Models”). Despite the difference in terminology, there are several goals that appear to be consistent among providers and researchers in this field. In addition to the cessation of physical violence, there is hope for longer-term reform beyond short-term cessation or interruption of violent behavior. Common objectives among providers are that participants develop empathy and be motivated to accept personal responsibility for their abuse (Alexander et al. 2010; Yorke et al. 2010). To date there are no studies that reveal a superior method or intervention style to achieve all of these goals for all offenders (Babcock et al. 2004). One of the reasons may be that batterers are not a homogeneous group nor is the level of violence the same in all cases, yet treatment planning, risk assessments, and BIPs have been slow to incorporate the findings from batterer

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typology research (▶ Chap. 97, “Psychological Theories of Intimate Partner Violence”). The current body of research clearly suggests that batterers are a heterogeneous group and therefore multiple intervention methods need to be considered rather than the standard “one-size-fits-all” approach (▶ Chap. 97, “Psychological Theories of Intimate Partner Violence”). Additional complexities to account for are that not all batterers are male, heterosexual nor are they of any particular race, religion, culture, or upbringing. Innovative intervention designs need to be varied to increase effectiveness with current clients and to help break the intergenerational cycle of IPV.

Measuring Effectiveness While there are no standardized methods for evaluating a program’s effectiveness, subjective and objective measurements are being utilized. Many programs utilize a subjective “exit interview” with questions designed to determine if the offender has “changed” and is now accepting personal responsibility for committing the abuse. Objective measurements are more elusive, and there is very little research available to BIPs to measure outcome success other than criminal justice searches for re-arrest statistics. Shepard and Campbell’s Abusive Behavior Inventory (Shepard and Campbell 1992) was modified by Yorke et al. (2010) to measure offender’s acceptance of personal responsibility and was renamed the Recognition & Personal Responsibility Scale (RPRS). Most offenders enter BIPs in the “precontemplation” stage, defined as not ready, and resistant to change. The University of Rhode Island Change Assessment (URICA) can assist practitioners who desire to measure where a client scores in the Readiness to Change Model (▶ Chap. 139, “The Efficacy of Psychosocial Interventions for Partner Violent Individuals”), and thereby modify delivery of services accordingly. The URICA and RPRS are two instruments that facilitate the objective measurement of whether reductions in minimization and denial are evident in clients. The development of more objective measurements can further the evaluation of program effectiveness and be of immense value to the field of BIPs and other systemic partners. Project Mirabal (Kelly and Westmarland 2015) is an example of the importance of choosing measurement outcomes that are more relevant to various stakeholders such as victims, program providers, and the criminal justice system. Rather than just evaluating re-arrest recidivism or whether a program participant “admits” to prior violence, Project Mirabel instituted a multisite longitudinal study using four programs and involved the victims of the participants in both initial design and outcome measurements. They recast the research questions and offered a “third generation” of analysis to redefine “success.” Six measures of success were identified based on interviews with the men in the program, the women involved in the abusive relationships, as well as program providers and funders of the project. These measures were described as: “respect and effective communication”; “space for action”; “safety and freedom from abuse for women and children”; “safe and positive parenting”;

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“enhanced awareness of self and others, including understanding the impact of their violence”; and finally “safer and healthier childhoods.” The feedback received from interviews with the participants, partners or mothers of their children, and program providers indicated that the BIPs (or Domestic Violence Perpetrator Programs) were fairly successful in achieving these more relevant areas of change.

Future BIP Designs While some men respond well to the pro-feminist, patriarchal theory promoted in the Duluth model of treatment (Paymar and Barnes 2007; Pence et al. 1993), not all clients are served well by this approach (Smedslund et al. 2011). This model presumes that men exert power and control over their female partners because society allows and supports this behavior. It relies heavily on the Power and Control Wheel to explain men’s violence. Multiple meta-analyses are finding that pro-feminism and patriarchy are not the only theories to explain IPV perpetration (▶ Chap. 97, “Psychological Theories of Intimate Partner Violence”; ▶ Chap. 102, “Intergenerational Transmission of Intimate Partner Violence: Summary and Current Research on Processes of Transmission”). Interventions that address offender needs of cognitive restructuring, emotional regulation, prior trauma, and healthy relationship skill building may result in higher retention rates and less recidivism. Social learning, development (e.g., from Maslow, Erickson, Kohlberg), and attachment theories (Bowlby, Ainsworth) can also guide successful interventions to increase effectiveness as they address how violence is often modeled and learned in childhood. Therefore, new healthy behaviors can be taught to replace previous unhealthy and abusive behaviors (Yorke et al. 2010). Clinical interventions such as motivational enhancement strategies (Scott et al. 2011) and Dialectical Behavior Therapy (DBT) (Waltz 2003) have shown efficacy in reducing attrition and recidivism when applied to IPV intervention. The motivational enhancement strategies help to reduce common resistance found among this population and thereby provide more opportunity for the participants to learn the new, healthy behaviors. DBT techniques address the common issues facing those participants who have borderline personality traits such as emotional deregulation and fears of abandonment. Individual treatment, as opposed to group work, is available in some jurisdictions, but some states in the United States prohibit its use in lieu of group. Recently research has shown some efficacy with certain cases to help reduce abuse (Murphy and Meis 2008). Some program providers have explored alternatives to perpetratoronly BIPs by offering abuse specific couple’s counseling (Geffner and Mantooth 2000). Couples counseling, even abuse specific types, is currently prohibited in most state mandates for BIPs, but research is examining the effectiveness of using it in lower level cases of IPV (▶ Chap. 141, “Couples Counseling to End Intimate Partner Violence”). Crossover from other disciplines, such as substance abuse, has informed newer intervention designs. Substance Abuse and Mental Health Services Administration (SAMHSA) recommends trauma-informed interventions that deal with co-occurring

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issues as important for domestic violence and substance abuse clients (SAMHSA, 2005, TIP 25). This is similar to the approach of more successful programs to change attitudes, beliefs, and behaviors from a more trauma informed and empowerment base as opposed to shame-based and punitive-oriented approach (e.g., Geffner and Mantooth 2000). Criminal justice research into offender rehabilitation suggest that interventions need to address life issues, or what is referred to in criminal justice parlance as “criminogenic needs,” such as antisocial beliefs and behaviors, substance abuse, or employment issues (Radatz and Wright 2016). Restorative justice is a newer, promising approach which originated in the 1970s from mediation efforts to repair broken relationships. The emphasis with this approach is on accountability and reparation, and is facilitated with meetings among victims, offenders, and members of the community which is viewed as more in line with feminist perspectives and can be seen as more acceptable to victims of IPV (▶ Chap. 95, “Feminist Perspectives of Intimate Partner Violence and Abuse (IPV/A)”). Some programs offer formats which introduce faith and spirituality into the group process which can supplement secular teachings about healthy relationships and help dispel misunderstandings of spiritual teachings which have been used at times to justify abuse (Jayasundara et al. 2017). Moral Reconation Therapy (MRT) makes use of peer groups to reduce the likelihood of re-offending by promoting and reinforcing healthy behaviors and sound moral reasoning (Ferguson and Wormith 2013). MRT is a cognitive-behavioral program, originally designed for substance abusers, but was later modified to address domestic violence offenders. BIPs were initially designed for male offenders of IPV and therefore programs for women who use force against their intimate partners is still underresearched and underserved. Women’s violence differs from men’s in regard to motivation, intent, and impact and therefore the intervention needs to be gender responsive. Koonin et al. (2002) created the Weaver Manual as one of the first to address female violence, and it has been followed by the work of Dowd and Leisring (2008) who have recommended a new framework for working with this population. Many of the participants have experienced trauma and abuse, and therefore trauma recovery, cognitive interventions, and emotional regulation are important components to help women respond to their distress in a less violent and aggressive manner (Mackay et al. 2018). In addition to the program designs for special populations, evaluations are needed to determine the optimum length of time clients need to participate in a program, and which types of clients need what length of time to change their attitudes, beliefs, and behaviors. In the United States, there is no single, consistent time frame for BIPs, with a range of 16–52 weeks required by different states in the US Sessions usually last from one to two hours each. Some states, such as Colorado, have instituted program requirements that are contingent on meeting certain “markers” of success rather than actual time frames (▶ Chap. 123, “Protection Orders: Shielding Intimate Partner Violence Victims from Harm”). More studies are needed to ascertain the ideal time needed to effectively change the client’s thoughts, feelings, and behaviors around the issue of IPV, and how to assess these key factors.

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Systemic Interventions for Offenders and Victims Eliminating IPV requires collaborative coordination among law enforcement, the courts, victim advocacy agencies, and BIPs to develop and implement standardized responses and sanctions. When the Duluth Model was conceived, it was designed to be part of a broader coalition of responses to address IPV offenders (Gondolf 2010). The Coordinated Community Response Model (CCRM) has been emphasized as necessary for a comprehensive systemic approach where the whole community is seen as the solution to stopping domestic violence (▶ Chap. 119, “System Response to Intimate Partner Violence: Coordinated Community Response”). In addition to BIPs, the components include law enforcement, the courts, and victim advocacy. Some communities have adopted Domestic Violence Coalitions, Councils or DV Task Forces with varying degrees of success in affecting the dynamics of domestic violence. Another area lacking in consistent systemic responses are the services and remedies for victims of IPV. For example, the criminal justice response is inconsistent when holding offenders accountable for various offenses, whether it is the difference in charges for the same act or the enforcement of violations of protective orders (▶ Chap. 123, “Protection Orders: Shielding Intimate Partner Violence Victims from Harm”). Furthermore, most services for victims are only accessible when the victim has chosen to leave the relationship, rather than providing assistance, counseling, and support for those who choose to stay with their partner. Addressing this discrepancy might significantly assist in eradicating the prevalence of IPV, especially when the abusing partner is receiving simultaneous services, and there is hope the intergenerational cycle of violence will stop. As noted elsewhere in this handbook (▶ Chap. 105, “Intersectionality and Intimate Partner Violence and Abuse: IPV and People with Disabilities”; ▶ Chap. 191, “Systems Responses to Older Adult and Elder Abuse”), systemic responses to IPV involving older adults and persons with disabilities (PWD) are fragmented and lacking in services and program options. For those older adults and PWDs, victims who are unable to care for or protect themselves and have no one willing or able to assist, the county and state adult protective service (APS) programs can provide case management, crisis intervention, and referral services to the courts, law enforcement, and other systems that can respond to interpersonal abuse that rise to the level of a crime. All 50 states in the United States have APS programs for older adults, and some can also respond to PWDs. Some county APS programs can refer older adult IPV victims to DV programs if they do not meet criteria for APS. If victims refuse services from APS, however, they cannot be served unless short-term orders are issued by a judge (see ▶ Chap. 191, “Systems Responses to Older Adult and Elder Abuse”). Most domestic violence shelter programs will not accept older adults or PWDs if disabilities require special services like home aides, medication administration, special handicap access, and services to meet other special needs (see Vinton 2003). One example of a shelter program that can meet the needs of PWD of all ages, assuming no dementia or serious and persistent mental health issues exist, is Barrier Free Living in New York City.

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There is an identified need for culturally responsive, trauma-informed approaches to the obstacles faced when older persons or PWD, whether the abused or the abuser, seek services. Utilizing entire communities to provide a more comprehensive approach to ending IPV with standardized systemic approaches to intervention must not be overlooked in designing future programs and services. The failure of the IPV field to disaggregate victims and perpetrators by age is an issue. For example, in batterers groups or even interventions for victims, there often are no older adults included. If they are included, we do not know if the interventions have a different effect based on age of victim or perpetrator. Some of the trauma-focused interventions discussed above could also be helpful to older adults. However, it is not clear whether older adults utilize these, and if they do, if they are helpful. Prevalence studies of IPV victims may not include subjects over the age of 49, creating the impression that older women do not experience IPV, and interventions may not include relevant programming for older victims needed to ensure this population utilizes and benefits from these specialized services (United Nations 2014). Domestic violence victims who are immigrants and refugees also face challenges escaping their battering situation beyond what victims with citizenship status experience. In addition to the trauma of abuse by a spouse/partner, they may also struggle with the possibility of losing children to the abuser if s/he is a citizen, and deportation. The Violence Against Women Act (VAWA) in the United States may provide some legal remedies through special visas that can be issued staying deportation, and provide access to limited resources for those who wish to leave their battering spouse with their children, but the process is complex and must be negotiated with legal assistance through non-profits with expertise in this work. Ideally, culturally congruent trauma-focused therapy for parents and children is provided but this is not always available (Brownell et al. 2020). Anti-immigrant sentiment and policies may complicate efforts to assist battered immigrant victims, particularly non-documented parents and children.

Sexual Abuse and Rape In considering the history of rape, prohibition laws were enacted as far back as the Greek and Roman Empires. Regardless of the fact that some early statutes punished the victim, perpetrators could buy their way out of prosecution or avoid public detection of their crimes. The efforts of women’s movements have brought definite measures of progress, but limited substantive changes in disclosure, apprehension, and prosecution of rapists (Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, National Crime Victimization Survey, 2010–2016, 2017). It is clear that more laws are necessary to reduce or eliminate sexual assault. Widespread campaigns are necessary to clearly define and increase awareness of sexual assault crimes, rehabilitation of perpetrators, and guide potential victims to increase their safety. In the last half-century, there have been three widespread movements that have advanced these aims: (1) Sexual

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Harassment in the Workplace (Civil Rights Act of 1964/Title VII); (2) Marital Rape Laws (South Dakota, 1975); and (3) The “Me Too” movement (Tarana Burke, 2006). These advances have provided credibility to consider and discuss topics such as sex-based discrimination, sexual harassment, unwanted touching, power differentials, predatory behavior, retaliation, nondisclosure agreements, and online sexual postings. Sexual abuse must be viewed in terms of how it fits into larger narratives of gender hierarchy, abuse of power, and our country’s general taboo of talking about sex.

Mass Public Campaign to Dismantle Rape Culture According to a National Sexual Violence Resource Center (NSVRC) study in 2018, sexual assault data reveal vast imbalances in that females are much more likely to be victimized and males are much more likely to be perpetrators. When reviewing more sexual assault cases in general, one in three women and one in six men are victims of sexual violence. Specifically, rape, according to the NSVRC report (2015), is committed against one in every five women, while 1 in 71 men are rape victims during their lifetimes. The US Department of Health and Human Services (2016) reports that 88% of documented cases of sex abuse are committed by males. Rape and sexual violence against children and adults are deeply gendered issues. In light of pervasive social conditioning in our society that reinforces gender hierarchy and male dominance, it is not surprising that “Rape Culture” continues (▶ Chap. 169, “Wartime Sexual Violence: A Historical Review of the Law, Theory, and Prevention of Sexual Violence in Conflict”). The term rape culture, initially used by feminists in the 1970s, refers to the normalization, justification, and tolerance of sexual violence toward women. Every woman is affected by this culture all the time. Most women live in fear of rape, while men do not have this fear. Women and girls are forced to limit their behavior and activities because of the existence of rape potential. Along with domestic violence, rape, and sexual assault function as powerful, intimidating tools that keep many in the entire female population in a subordinate position to the male population. In “Against Our Will,” Susan Brownmiller stated: “Rape is nothing more or less than a conscious process of intimidation by which all men keep all women in a state of fear” (Brownmiller 1975, p. 15). Rape culture and gender hierarchy persist in our society due to patriarchal attitudes and gender inequalities embedded in language and behavior that have existed for a very long time (▶ Chap. 96, “Masculinity and Violence Against Women from a Social-Ecological Perspective: Implications for Prevention”). Recognizing it is the first step to dismantling rape culture. Society must begin to examine and evaluate the impact of media messages about gendered violence, often gratuitous, in movies, television, and video games; conditioned pressure on men to “score”; conditioned pressure on women not to appear “cold”; assumptions that only promiscuous women get raped; everyday speech that serves to

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objectify and disparage women; popular songs that degrade women; practices such as child marriage and female genital mutilation; and so-called jokes at the expense of women. The #MeToo Movement has raised public consciousness about relevant topics regarding sexual assault and sexual harassment (▶ Chap. 169, “Wartime Sexual Violence: A Historical Review of the Law, Theory, and Prevention of Sexual Violence in Conflict”). Interventions must focus on education of appropriate vs. inappropriate comments, gestures, and actions; the facilitation of expression of victim’s voices; and strict protocols of accountability in cultural, educational, business, and legal institutions. Widespread education needs to include understanding of concepts such as physical space, overt consent, zero tolerance, power differentials, victim-blaming, flirtation, harassment, quid pro quo harassment, molestation, assault, stranger intrusion, and bystander intervention. Additional interventions include: intentional use of language that disrupts traditional gender mythologies; improved vetting of authority figures in schools, churches, law enforcement, and the military; and providing space for men to speak up about their victimization (#Metoomen). MacKinnon (2019) addressed the concomitant need for gender equality, which incorporates equal pay, equal hiring, equal numbers of women on corporate boards, and more women in politics as a path to derail sex harassment. The necessity of a cultural shift beyond the passage of more laws is indicated in her sentiment that the illegality of a practice does not equate to the prohibition of that practice. To end rape culture, perpetrators, regardless of status, need to be identified and held accountable for their crimes. Criminalization of sexual harassment and sexual assault represents the beginnings of cultural change, as these misdemeanors or felonies must be enforced and prosecuted. There needs to be zero tolerance for rape and assault in the home, on the streets, and in workplaces. There can be no impunity for offenders, regardless of circumstance or position of power. Future interventions to dismantle rape culture must also address implicit, unconscious biases that elevate the male above the female in power and prestige. A relatively unexplored root of rape culture involves the extremely influential and pervasive reference to God or the Deity as male in most religions. Whitehead, in his study of the effects of the masculine image of God, stated that: “Individuals who view God as masculine are signaling a belief in an underlying gendered reality that influences their perceptions of the proper ordering of that reality” (Whitehead 2014, p. 1). The mere discussion of this subject seems to be taboo and sacrosanct. To the present day, most organized religions have disseminated the idea that males are supreme. Hence, men take their collective cue and feel entitled to rule, and this often includes in the family. The findings of Whitehead’s study promote the need for future research regarding the impact of a gendered deity on individuals, as well as various cultural institutions. It might be illuminating to initiate frank discussions among civil rights leaders, feminist activists, religious leaders, and sociological and anthropological scholars on this topic.

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Address Barriers to Reporting Sexual Assault Even more than other types of abuse, sexual assault thrives in secrecy due to extreme privacy taken during the act and intense shame that leaves an enduring mark on victims. It has been estimated that at least 60% of sexual assaults are never reported (Rennison 2002; Wilson, 2015). This is likely a very conservative percent. There are several pervasive factors that both women and men face that explain the great difficulty reporting sexual abuse or the delay in reporting (D’Anniballe 2010). Society perpetuates an entrenched skepticism about accusations of sex abuse, which belie consistent research that shows false allegations to be quite rare, with occurrence ranging from 2% to 10% (Lisak et al. 2010). Despite the #MeTooinspired greater awareness of frequency of sexual assault, many victims have lost faith in the justice system due to their treatment of women and the fact that powerful men who perpetrate often avoid prosecution (Bevins & Loughnan, 2019). The nature of sexual assault, the deeply personal violation, exacerbates the shock, disorientation, and even dissociation of the trauma. Hence, victims may struggle to recall precise details of the event, and often present with non-stereotypical behaviors, which tend to be misinterpreted by uninformed representatives of the justice system as falsification, contrivance, or fabrication (Lorenz et al. 2019). Based on experiences of other women, victims who do disclose, report fear, insensitive responses that result in blame, shame, and stigma. Additionally, there exist real threats of personal repercussions in the form of retaliation by the perpetrator, impact on employment, privacy violations, and legal ramifications. The likelihood of re-traumatization presents another obstacle to reporting, as immediate recounting of events often elicits vivid and traumatic flashbacks, memories, images, and emotions experienced during the intrusive assault. Investigators often bring further intrusions in the form of personal questions, intensive physical exams, collection of evidence, painstaking cross-examination on the stand, and public scrutiny of the victim’s dress, manner, mental state, motives, sobriety, and history (Lorenz et al. 2019). For survivors, unsupportive and intrusive responses by the criminal justice system cause much doubt about the viability of their case.

Trauma-Informed Intervention for Victims Trauma-informed practice would serve as a corrective measure for the loss of control experienced by victims during and subsequent to the assault, as well as support modifications of existing protocols that provide choice for survivors. Studies reveal that cognitive processing therapy (CPT), exposure-based therapies (EBT), and eye movement desensitization and reprocessing (EMDR) had statistically significant reductions in PTSD and symptoms of depression compared to control groups (Regehr et al. 2013). More research is in order for existing psychological interventions, such as critical incident stress debriefing (CISD), critical incident stress management (CISM), psychological first aid (PFA), and cognitive restructuring therapy (CRT). Each of these therapies represents secondary or tertiary interventions

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intended to prevent and/or limit the development of trauma-related symptoms shortly after exposure to any traumatic event. Tertiary intervention programs address those who have been sexually assaulted or raped. In a survey of effective treatment for survivors, several strategies have achieved some degree of efficacy, including immediate provision of resources for both medical care and psychotherapy, communicating that support is available, breathing retraining, video-based secondary prevention programs, education on co-occurring PTSD and substance abuse/eating disorders, and self-help resources in the form of support groups, websites, and mobile apps (▶ Chap. 173, “The Contemporary Study of Adult Survivors of Interpersonal Violence and the Development of Mental Health Treatment”; Gilmore et al. 2018).

Changes to the Criminal Justice System In accordance with the theme of restoring a sense of control to victims, it is imperative that survivors have a voice and provide input into how the criminal justice system deals with sexual assault (Kirkner et al. 2017). Typically, legal reforms focus on improving conviction rates, with little emphasis on increasing sensitivity to victims. The question must be asked whether prosecutions leading to conviction are successes if survivors are damaged and retraumatized in the process. Court personnel can be educated that PTSD is a natural sequela of sexual assault, which explains why survivors go to great lengths to avoid thinking about or discussing the incident. To recount details of a traumatic event on a witness stand forces victims to relive their trauma in public. With an understanding of psychological effects of sexual assault, judges and juries gain more balanced perspectives on strategies of defense attorneys who use lapses or inconsistencies in memory to undermine victim testimony. In a review of recommendations on reporting from RAINN (Rape Abuse and Incest National Network) and the International Association of Chiefs of Police (IACP) Leadership Initiative on Violence Against Women (2015), several promising modifications emerge that are intended to eliminate secondary traumatization of victims: (1) provide opportunities to report anonymously by phone directly to police to eliminate uncertainty of third party reports; (2) provide opportunity to prepare for police interviews rather than be pressured to provide statements on the spot (when survivors may be in shock, without sleep, or intoxicated); (3) provide survivors options for the location of the interview; (4) provide options to have interviews conducted by plain clothes officers of the same gender; (5) allow for survivors to have support with them, at both reporting and interviewing stages (Patterson and Campbell 2010); and (6) at the outset, interviewers and hot line personnel can relay to survivors that their revelations do not automatically force a trial. With each of these practices, the risk of re-traumatization is reduced by allowing anonymity and thereby limiting exposure (of shame), by providing options so as to create greater sense of choice and fewer feelings of coercion, and by allowing time to prepare (with support) in order to dissipate the likelihood of a forced interrogation.

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With efficient streamlining, the criminal justice system process can spare survivors the burden and trauma of having to repeat their stories of assault many times to different personnel. It is feasible to house multiple services for survivors in one location (i.e., medical services, police interviews, legal assistance, victim advocates, counseling, etc.) along the lines of the Family Justice Center for IPV (Simmons et al. 2015). The Sexual Assault Response Teams (SARTs) were created in order to improve victims’ experiences and legal outcomes by coordinating the work of medical, mental health, and legal systems (see ▶ Chap. 162, “Interventions in the Aftermath of Sexual Violence: Justice, Advocacy, and Treatment”). Similarly, the Sexual Assault Nurse Examiner (SANE) programs are meant to conduct forensic exams with enough sensitivity for victims to regain a sense of control. A primary goal of these intervention programs is to prevent further traumatization of victims, and according to a recent study, both SART and SANE receive higher satisfaction ratings than police personnel or state attorney staff (Henninger et al. 2019). By taking cultural diversity into account, all services can be made available in survivors’ own languages (▶ Chap. 164, “Military Sexual Trauma”). Communitybased supports can be utilized to proactively identify women in immediate distressful situations through interagency communications among domestic violence shelters, child protective services, sexual assault agencies, and immigrant support services. Survivors face inordinate difficulties in the aftermath of assault and must have access to psychological, legal, and advocacy support throughout the legal process. They are entitled to separate legal representation, the guidance of an advocate, and support of a friend or family member of their choosing. With the support of a team approach, survivors may be more likely to receive appropriate medical care and less likely to be treated negatively by the police (Rich 2019, 2021). Court systems in the United States and most of the Western world are based on an adversarial system, where rights of the accused are prioritized, leaving courts in the position of impartial referee between the prosecution and the defense. Many rape advocates suggest a shift to an inquisitorial system, where both state and court are actively involved in investigating facts of the case (Smith and Skinner 2012). More recently, a procedural system of justice has been advanced, where all parties involved in the legal system receive equal and fair treatment (Lorenz et al. 2019). In the current system, the prosecution’s burden is to establish the guilt of the accused, beyond a reasonable doubt, while the defense’s complementary task is to attack arguments made by prosecution, as well as the credibility of the victim. Essentially, this places the victim in the defensive position, with the result being that victims feel guilty until proven innocent. Parallel systems of justice, reconciled with the Constitution, can be employed that provide protections for both victim and accused.

Bring Men Along To sustain the #MeToo movement, both men and women suggest that men must join and add their support. Currently, many men have a sense of uncertainty about

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interacting with female acquaintances or colleagues and many feel left out of the movement. Yet others express interest to be educated about differences between appropriate behavior toward women and predatory behavior. GQ Magazine noted that the #MeToo Movement opened our eyes that sexual assault and harassment are widespread, so it is time for men to join the conversation ( 2018, May). GQ also reports that the #MeToo movement called for men to be quiet and listen. It is time to begin conversations about how we fix the structural problems (2018, May). Community and nationwide dialogues aimed at redefining the meaning of masculinity in the twenty-first century provoke reevaluations of centuries-old traditional male roles (▶ Chap. 158, “Men Stopping Violence’s Definition of Male Sexual Violence Against Women: Implications for Prevention and Intervention”; ▶ Chap. 96, “Masculinity and Violence Against Women from a Social-Ecological Perspective: Implications for Prevention”). There exist several men’s programs that promote dialogue focused on redefining rigid gender stereotypes and masculinity, as well as listening to and partnering with feminist groups. These programs are recently formed and represent fruitful areas for research as to their effectiveness. Futures Without Violence (https://www.futureswithoutviolence.org/our-mission/) and The Good Men Project (https://goodmenproject.com/featured-content/man-man-21st-century-shfr/) are nonprofits founded by women for the respective purposes of defining what it means to be a “good man” and ending sexual and domestic violence. The Good Men project is meant to allow men a forum to tell stories of defining moments in their lives and discover how to be a good man in today’s world. Futures Without Violence is focused primarily on ending domestic violence, with the engagement of men as positive role models serving as a key feature of the program. The MenEngageAlliance (http://menengage.org/wp-content/uploads/2016/06/e-Dia logue-Report_V5.pdf) has an annual presence at the United Nations Commission on the Status of Women. In 2016, this worldwide organization published a report titled, “Critical Dialogue on Engaging Men and Boys in Gender Justice,” centered on accountability, patriarchy, privilege, and intersectionality. It is crucial to promote self-reflection, discussion groups, and artistic creations centered on current meanings of gender that incorporate an understanding of gender fluidity and feminist principles. It is no slight to men to become feminists. To the contrary, it would be a boost to men’s self-esteem to promote the women in his life.

Intervention for Offenders Sex offender programs usually comprise assessment and treatment at postconviction and pre-sentencing stages of the judicial process. At present, there does not appear to be conclusive results regarding the effectiveness of treatment for child sexual perpetrators (▶ Chap. 35, “Adult Sex Offenders Against Children: Etiology, Typologies, Investigation, Treatment, Monitoring, and Recidivism”). Overall, treatment for sex offenders concentrates on teaching strategies to stop abusive behaviors and enhancing the ability of clients to take responsibility for their actions. Studies suggest that mental health treatment programs significantly reduce recidivism for

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both adult and juvenile offenders (Evans et al. 2019). Typical treatment approaches can be classified as Holistic Cognitive-Behavioral Therapy (Evans et al. 2019), which encompasses cognitive reframing, modification of cognitive distortions, victim empathy, accepting responsibility, controlling sexual arousal, improving social skills, developing support networks, and establishing conditions of supervision. An important aspect of the therapy is the ongoing monitoring, updating, and implementing of a relapse prevention or risk management plan. The US Department of Justice recommends tailoring treatment approaches to specific individuals according to their unique needs, risks, and methods of perpetration (Przybylski 2015). Considering that the impact of sexual abuse is both traumatic and long-term, and the fact that the majority of sexual assaults are not reported to any authority, additional steps must be taken in order to more substantially address the problem. The many cases of sex abuse that never come to light reveal the need to identify “potential sexual offenders” or “unconvicted perpetrators” (Gibbels et al. 2019). Research is paramount in order to establish definite correlations between sexual abusers and the many contributing factors, so as to identify potential offenders. Treatment providers specializing in incest perpetrators face enormous and complex challenges. Frequently, there is co-occurring abuse involving other family members, and there may exist more than one incest victim in the same family. Therapists often find themselves faced with the task of breaking the cycle of intergenerational transmission of sex abuse. The entire family must be involved in the lengthy treatment process. Denial and apathy must be overcome with engagement of the non-offending parent. The perpetrator needs to be seriously involved in their own treatment, and the abused child must have their own separate therapy. Only when all three components are effective enough to indicate sufficient progress can the work of family reunification begin. The culminating stage of treatment involves the child, with non-pressured guidance from the therapist, being able to confront both the perpetrator and the non-offending parent in a room with the therapist. Safeguards must be included in such programs.

Actions That Can Be Implemented Now Engagement with survivors of sexual assault to understand their experiences would hopefully bring about greater empathy for and less violence toward women. Survivors need support, as well as opportunities to recover and thrive. Indeed, many of the leaders in movements that promote a more tolerant, violence-free society are women who have recovered from assault, rape, domestic violence, and/or sex trafficking. With current movements such as #MeToo, #TimesUp, #GenerationEquality, #BalanceTonPorc, and #NiUnaMenos, opportunities abound to dialogue with or join those fighting for equal rights for women. Education of the next generation about gender equality, along with challenging stereotypes encountered in the media, streets, and schools, are important aspects of primary prevention as an intervention. Families must be secured as a safe place for

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children to flourish and learn the importance of consent at a young age. Initiatives already exist to foster careers for young women. STEM, Science Technology, Engineering, and Math (https://www.stemforher.org/), was formed to create awareness and opportunity for women to pursue what were formerly male-dominated jobs. The Global Funds for Women (https://www.globalfundforwomen.org/) promotes the idea that “women’s rights are human rights.” Through the hiring and promoting of women, the amplification of female voices can create a balance to our patriarchal world (▶ Chap. 158, “Men Stopping Violence’s Definition of Male Sexual Violence Against Women: Implications for Prevention and Intervention”). The continuing assaults, rapes, and wars, generation after generation, require that we hear different voices. We need the influence of the previously muted majority, women. Acceptance, respect, and love for humankind equates to acceptance, respect, and love for all races, religions, cultures, ages, and sexual orientations.

Abuse of Older Adults With the projected growth of the older adult population in the upcoming decades (Ortman and Hogan 2014), there is heightened urgency in identifying, quantifying, and addressing more comprehensively the scope and scale of the elder abuse problem at the national level. In particular, there needs to be a sharpened focus on determining effective interventions, prevention strategies, and approaches to policy development and implementation to reduce victimization of older adults (see ▶ Chap. 186, “Sexual Victimization of the Elderly: An Examination of the Emergent Problem”). While public health perspectives and strategies offer a promising approach to strengthening responses to neglect, abuse, and violence against older adults, there are significant limitations that currently exist in both healthcare provider and public understanding of public health frameworks for older adult abuse. Efforts focused on elder abuse identification and mitigation of harmful effects still remain only in the beginning phases of development, and stratification of interventions across the classic primary, secondary, and tertiary public health prevention categories also remain in very early stages. Researchers, healthcare providers, and social service workers continue to grapple with the basic prevalence, social determinants, and consequences of elder abuse. Global public health strategies for older adult abuse that target the social structural conditions of elder abuse at a population level and formulation and implementation of racially, ethnically, and culturally sensitive public health policies responsive to community needs are very much a second generation movement in the older adult abuse field. Effects of abuse of older adults on the longer-term physical health, cognitive, and psychosocial outcomes are only beginning to be elucidated in studies. Research needs to broaden its goals to include a sharpened focus on intersectionality and chronic health and mental health conditions. Public health strategies for addressing healthcare needs will be advanced through identification of abuse and violence and

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design of robust interventions that include comprehensive social services to protect the most vulnerable older adults. In spite of these limitations and challenges, the elder abuse field has developed significantly since its inception in the 1970s. Research on elder abuse was stimulated by the work of the late Rosalie Wolf, considered the founder of elder abuse research. Much of this work has been interdisciplinary, with medicine, law, ethics, nursing and social work, and other relevant disciplines collaborating and developing capacity internally to respond to abuse of older people within the changing demographics of aging (Burnes et al. 2020). As a result, important research initiatives have broadened our understanding of prevalence, risk factors, and other dimensions of elder abuse within aging, social ecological, public health, and interdisciplinary frameworks. Much work still needs to be done to bring elder abuse into the domestic violence (DV) field. Scholars in the 1980s and 1990s began to consider elder abuse within a feminist perspective, and some limited intervention research on elder abuse in this frame was initiated (United Nations 2014). Feminist gerontology has also been developing as a perspective within social work more broadly. Integrating elder abuse within the DV framework has resulted in increased understanding of why older women have been invisible as victims and survivors of intimate partner abuse. Novel research methodologies have also emerged from the European Union and World Health Organization in examining prevalence of abuse experienced by older women (Garcia-Moreno and Pallitto 2013). Successful advocacy has resulted in the inclusion of older women as a category within the Violence Against Women’s Act (VAWA) of 2000, and certain VAWA grants are now directed to programs serving older women (Brownell et al. 2020). On a local level, higher levels of engagement in advocacy and education in collaboration with DV organizations are needed so that such DV programs recognize how to meet the needs of abused older women (Vinton 2003). For example, DV shelter programs funded by Temporary Assistance to Needy Families (TANF) may not get reimbursed for serving older women without dependent children and counseling may focus on needs and concerns of younger women with children. Adding programs specifically targeting older women will broaden the range of resources available. Advocacy moving forward that strives to link local policy initiatives to state and national initiatives will also be important in order to target abuse of girls and women of all ages. One challenge is the siloed nature of current funding mechanisms that can pit child abuse, domestic violence, and elder abuse advocates against one another. An integrated approach to addressing domestic violence across the lifespan could ease some of the tensions inherent in the current competition for funding across siloed service systems (see ▶ Chap. 185, “Intimate Partner Violence in Later Life”). Although the recognition of older adults as an important service population to be served by domestic violence programs has improved over the past decade, there remains a great need for aging services professionals, including elder abuse practitioners, to enhance collaboration with the domestic violence field. More research is needed to better understand the prevalence, nature, and impact of IPV in later life as a subcategory of interpersonal violence in its own right, including the impact of social

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and economic determinants of health, including gender, race/ethnicity, disability, sexual orientation, health and other disparities, in the broader context of risk for IPV across the lifespan (see ▶ Chap. 185, “Intimate Partner Violence in Later Life”). Although many in the violence prevention field are inclined to focus their efforts on youth, understandably motivated by the potential for breaking the cycle of violence before it begins, the magnitude of the aging population in the United States (and many other countries) requires attention also be paid to older victims of IPV. However, work to disrupt the perpetration of violence among children and youth is not at cross-purposes with efforts to better understand, address, and prevent abuse in later life. Indeed, trauma earlier in the life course can predispose individuals to unhealthy and potentially violent relationships as they grow older. Given that older adults in general have poorer reported health than younger persons, it is important to consider the physiological toll of all forms of partner violence on aging minds and bodies. To integrate elder abuse within a re-envisioned field of family violence, we need to move beyond a siloed approach that understands abuse only as child abuse (vulnerable dependent) and spouse/partner abuse (reproductive age women as victims/survivors). These siloes, as applied to elder abuse, have resulted in a bifurcated framing of the elder abuse problem, namely, a misunderstanding of older adults as either frail care-dependent victims or as invulnerable to abuse by family members in later life. It has also obscured an identified factor in elder abuse: abuse experienced earlier in the lifespan predicts a higher likelihood of abuse in older adulthood. While theory has lagged behind observation, a growing body of research has demonstrated that interpersonal violence is a life-span issue, rather than one that occurs at independent, discrete stages (Maschi et al. 2012). A model of intervention in which interpersonal violence is approached within the context of cumulative disadvantage might more effectively address the developmental impact of abuse and trauma. Only recently has trauma been considered a factor in elder abuse. Increasingly, trauma-focused care models are evolving in the fields of child abuse and spouse/ partner abuse. However, trauma treatment for abuse of older adult victims has not been well developed yet. Practitioners and researchers are beginning to develop and assess trauma-focused interventions and care (Ernst and Maschi 2018). As this moves forward, it has required challenging an ageist bias in the field of DV. Promising intervention models include psycho-educational support groups, groups promoting spirituality in healing from trauma of familial abuse, interventions to target co-occurring depression and abuse of older adults (Bowland et al. 2012; Bright and Bowland 2008; Brownell and Heisler 2006; also see ▶ Chap. 194, “Intersectionality of Elder Abuse and Mental Health Issues: Needs and Interventions for Victims”), and trauma in relation to older adults’ experiences of financial exploitation (see ▶ Chap. 187, “Recognizing the Trauma Experienced by Community-Dwelling Older Victims of Financial Abuse Perpetrated by Trusted Others”). One challenge among many in addressing abuse of older adults is the wide age span this encompasses. Using both the definition of old age in the Older Americans Act and the United Nations, old age starts at 60 years and ends at death, which could

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include ages that exceed 100 years old. Clearly older adults falling within the old age cohort are diverse, but all must confront the possibility of ageism within the multiple settings in which they live. Ageism puts older adults at risk of being stereotyped and targeted for discrimination. This may occur for those residing in the community, older workers in the workplace, or older adults accessing healthcare and social services. For example, discrimination based on age, such as in the allocation of scarce resources during pandemics (▶ Chap. 196, “Intersectionality of Race, Ethnicity, and Culture in Neglect, Abuse, and Violence Against Older Persons: Human Rights, Global Health, and Systems Approaches in Pandemics”), not only violates civil rights laws but places older adults at heightened risk of abandonment and neglect, abuse, and violence. Older workers, for example, may confront ageism within the workplace. Counseling older workers to confront and develop coping strategies for ageist stereotyping and discrimination in the workplace is a future direction for workplace interventions (Jackson 2013). While a promising practice, to date this has not been manualized or evaluated to determine effectiveness. One myth of aging is that older people are dependent on younger family members for care and support. In fact, in interviews with older women caring for impaired adult sons, they express feelings of responsibility for their sons’ well-being, in spite of experiencing what they defined as mistreatment from their sons, and they expressed a felt need to protect them (see ▶ Chap. 195, “Mothers’ Perspectives on Abuse by Adult Children”). Programs for mentally ill and substance abusing adult children could include counseling with older parents. The Elderly Crime Victims Resource Center at the New York City Department for the Aging provides counseling for older victims of abuse by impaired adult children (Brownell et al. 2000).

Polyvictimization Later life polyvictimization is defined as older adults who experience multiple forms of abuse and/or abuse perpetrated by multiple abusers (see ▶ Chap. 189, “Polyvictimization and Elder Abuse”). Older victims of poly abuse comprise a complex, underserved, traumatized, and endangered group, urgently requiring attention, protection, and justice, and the problem of polyvictimization in later life represents a little understood, under-researched issue. The social ecological model has a robust evidence base and is widely viewed as a strong fit for the purposes of studying polyvictimization of older adults, as well as caregiving and elder abuse (see ▶ Chap. 193, “Caregiving and Elder Abuse: A Complex Relationship”). In recent years, lawyers and other advocates have made many efforts to improve the response of the criminal legal system to elder abuse, including increasing prosecution of elder mistreatment perpetrators and financial exploitation of older people. Challenges exist in bringing these cases to justice including the reluctance of victims to testify against family members, and concerns about the ability of victims to be reliable witnesses. The criminal justice system needs the support of various other systems (e.g., mental and physical health, social and aging-related services

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including Adult Protective Services (APS), and banking and other financial services), and the knowledge contributed by different types of professionals in prosecuting these cases, according to Heisler (2012). Over the past 20 years, the development of multidisciplinary teams has facilitated the process of bringing many more elder abuse cases to justice. The need to expand efforts to create multidisciplinary teams and study the effects of these teams remains a priority (see ▶ Chap. 191, “Systems Responses to Older Adult and Elder Abuse”). Ultimately the absence of systems, programs, and services capable of preventing and treating elder abuse in a caregiver context can leave abusing caregivers to manage on their own with potential dire results. Appropriate interventions need to be implemented whether the older adult victim is the recipient of family care or the caregiver of the abuser. For example, IPV may occur between older spouses when one is suffering from dementia and the other is their caregiver. VandeWeerd et al. (2013) developed a training intervention for caregivers to help them understand the triggers for abusive behavior on the part of their dependent spouses and to minimize abuse behavior on the part of both dependent and caregiver spouses. Future work to address neglect and abandonment of care-dependent older adults needs to involve more forensic evaluation centers, as well as the utilization of telehealth and telecommunication delivery systems. The goal is to help prevent or at least forestall the serious negative health impact of neglect and abandonment and provide senior members of society with the dignity and respect they deserve. Neglect implies care dependency, which is generally caused by physical and cognitive impairment related to age along with underlying mental health issues. Neglect frequently also involves a lack of, or inadequate caregiving, which may raise the issue of interventions like guardianships. Types and contexts of guardianships need to be investigated so as to ensure the necessity of guardianships, and when appropriate, supervision of caregivers under formal oversight systems (see ▶ Chap. 188, “Neglect and Self-Neglect of Older Adults”). Guardianships have been identified as protective for neglected and self-neglecting older adults who are unable to manage their finances and their person and as having the potential for abuse (Teaster 2018). They are an example of a civil intervention strategy (see ▶ Chap. 187, “Recognizing the Trauma Experienced by Community-Dwelling Older Victims of Financial Abuse Perpetrated by Trusted Others”). Financial exploitation is receiving considerable attention, yet the impact on victims of this type of crime is not adequately understood. The link between financial exploitation and trauma has been discussed but requires further development (Ernst and Maschi 2018). In general, financial abuse lacks compelling theories or conceptual models, and financial exploitation measures to advance research are often lacking or inadequate. The etiology, ebb, and flow of financial exploitation cases have yet to be clearly established, hampering the ability to devise interventions. Many financial offenders have a history of trauma that may impact their behavior, so the motivation for financial exploitation offending may be more complex than greed alone. Adult Protective Service (APS) workers generally find financial exploitation more difficult to investigate than other forms of abuse (Jackson and Hafemeister

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2011), and the field is also hampered by inadequate training in these investigations. In general, the process of investigating financial exploitation is nearly devoid of evidence-based practices. Once exploitation is identified, APS workers are ill-prepared to respond to the needs of victims as interventions are lacking. Some community guardianship programs have been developed, for example in New York City APS, where a special unit has been set up to receive social security and supplemental security payments that are used to pay for rent and other necessities like food. This program also extends to community-based nonprofit organization under contract with the New York City Department of Social Services, the Human Resources Administration (Jewish Association for Services to the Aged – JASA 2020). APS clients must agree to this arrangement, however, and not all local county jurisdictions have the funding and staff to carry it out. However, interventions, especially when introduced systemically, can be effective in protecting vulnerable older adults and helping them continue to live in their communities. Those states that include financial institutions and banks as mandated reporters of elder abuse have some authority to require financial institutions to report suspicious banking activity for vulnerable older adults to law enforcement and APS. For states without mandated reporting of suspected elder abuse and exploitation by financial institutions in state statutes, reporting is voluntary and failure to do so is not sanctioned (Comizio et al. 2014). Legislative advocacy in non-reporting states may help to remedy this gap. There is a definite need for more research on elder abuse offenders and intervention programs to reduce such exploitation other than jail. Noting the heterogeneity of elder abuse perpetrators, Jackson (2013) proposes distinguishing among types of elder abuse, including financial exploitation but also physical, psychological, and sexual abuse. For example, spouse/partners are found to be more likely to perpetrate physical and psychological abuse, other family members and care workers more likely to exploit financially, and spouse/partners but also nonfamily acquaintances were found to be more likely to perpetrate sexual abuse. Implications for interventions include a more punitive response involving law enforcement or the courts for intentional abuse, and psychoeducational programs for unintentional abuse or neglect. Victims often choose to remain in exploitative relationships with the one person with whom they have an emotional attachment. Identifying ways to ensure the financial safety of older adults is critically needed. Some states, for example, California, include bank employees as mandated reporters of suspected elder financial exploitation to APS. This promotes targeted training for bank and other financial officials to recognize the signs of potential exploitation of older clients. However, other states and financial institutions are reluctant to embrace this protective strategy because of concerns about privacy and liability (see ▶ Chap. 187, “Recognizing the Trauma Experienced by Community-Dwelling Older Victims of Financial Abuse Perpetrated by Trusted Others”). Multidisciplinary Teams (MDTs) investigate and make recommendations to Adult Protective Services programs and law enforcement (see ▶ Chap. 191, “Systems Responses to Older Adult and Elder Abuse”) as to an appropriate course of

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action for vulnerable older adults who may be experiencing polyvictimization, including financial abuse. An extension of this model includes forensic centers, when abuse is criminal. Telehealth is a virtual program for making psychiatric assessments in cases where distance precludes timely in-person assessments, and in rural areas where there is a dearth of professional staff. One model is currently undergoing evaluation in Texas (see ▶ Chap. 188, “Neglect and Self-Neglect of Older Adults”). Significant gaps exist in the elder sexual abuse literature and associated empirical research across virtually all measurable criteria. Elder sexual abuse is often subsumed in the overall category of elder abuse, which is dominated by explorations of physical abuse with limited research focusing solely on sexual violence. The lack of more concrete specifications in abuse type has resulted in a complex mix of contradictory findings, making it difficult to create strong recommendations for policy improvements and prevention practices. Uniform criteria to deal with elder sexual abuse do not currently exist for congregate care facilities, such as nursing homes and hospitals. There are no formal guidelines or policies governing this area and they need to be developed, along with training for staff in these facilities (see ▶ Chap. 186, “Sexual Victimization of the Elderly: An Examination of the Emergent Problem”). The distinction between forced and consensual sex in long-term care settings is a topic of concern to congregate care facility management, particularly when dementia is an issue with residents. Although sexual activity between staff and residents is never appropriate and is considered criminal in nature, sex between residents or between residents and their spouse/partners not living in the facility is more controversial (The Society for Post-Acute and Long Term Care Medicine 2016). While long-term care policy is typically set by state licensing entities such as state health departments, there is room for discretion by individual facilities. Intersectionality includes various structural components such as age, gender, culture, race and ethnicity, sexual orientation, geographic location, mental health and disability status, and other social determinants that uniquely converge to contribute to older adult victimization (see ▶ Chap. 196, “Intersectionality of Race, Ethnicity, and Culture in Neglect, Abuse, and Violence Against Older Persons: Human Rights, Global Health, and Systems Approaches in Pandemics”). Mental health issues of both perpetrator and victim are not always examined in elder abuse situations. However, these are often critical to designing and implementing effective intervention strategies, particularly when the abuse situation involves family members and significant others. Future work should integrate evaluation of mental health needs of both victims and perpetrators into elder abuse services. Mental illness can be a factor for both older adult victims and abusers. For victims, depression can be seen as a response to living with abuse, but it can also be a deterrent to the victim’s addressing the abuse by family members and loved ones. A promising empowerment-focused intervention, PROTECT addresses the intersectionality of abuse and depression on the part of the older victim by helping the victim take steps to create boundaries with the abusive family member and develop a stronger sense of agency (see ▶ Chap. 194, “Intersectionality of Elder

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Abuse and Mental Health Issues: Needs and Interventions for Victims”). Victims and perpetrators may both struggle with mental health issues that are viewed as affecting the victim-perpetrator relationship. In addition, the sequelae of abuse can precipitate mental health issues. Yet despite the overlap, it is only more recent inquiry into abuse risk frameworks that has highlighted the interface of mental health and abuse. Although prevalent in the 1990s, elder abuse research with diverse communities, such as Black/African Americans, American Indians, Latin, Asian, and others, has lagged in recent years. However, while older adults are disproportionately affected by COVID-19, particularly those living in congregate settings like nursing homes and prisons, Black/African Americans and Hispanic/Latinx are disproportionately affected by COVID-19 in infection rates, hospitalizations, and deaths. American Indian reservations are struggling with the effects of infection on health and economic security of its members (▶ Chap. 196, Intersectionality of Race, Ethnicity, and Culture in Neglect, Abuse, and Violence Against Older Persons: Human Rights, Global Health, and Systems Approaches in Pandemics”). A call for heightened attention to the safety of older adults living in diverse racial/ethnic communities is timely. A future directions objective is ensuring that interventions are tailored to meet the needs of communities of color and racial and ethnic minority older adults in institutional settings. In the past 40 years there has been a slow but steady paradigm shift in re-conceptualizing aging and elder abuse. This paradigm shift views old age as a vital and engaged phase of life where older people participate fully in their families and communities and make significant contributions to society. While vulnerabilities associated with aging including elder abuse are acknowledged as part of this paradigm shift, the emphasis is on strengths, social justice, and human rights. Most older people are not vulnerable or dependent, but even those challenged by ill health and disability (e.g., those in institutional settings) still have rights, especially those with minority status. ▶ Chapter 184, “Introduction: Abuse in Later Life,” focused on this in the chapter on the COVID-19 pandemic and skilled nursing facilities. The public health perspective they bring to the discussion on elder abuse is a critically important one. One of the many aspects of the handbook project that stands out is the effort of the elder abuse section authors to bring aging and elder abuse into a life course perspective. Much of the early research on elder abuse depicts older victims as frail, care dependent, and without voice who need professionals to speak for them. We hope to challenge this here.

Key Points • An important approach to intervene in child abuse is through public awareness marketing campaigns (including website access), which include a National Hotline focused on Positive Parenting. • No current single program or intervention to counteract IPV has shown to be superior, but rather multiple modes of intervention are showing stronger impacts that are tailored to the individual.

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• While societal customs determine the permissibility or criminality of specific sexual acts, a mass public awareness campaign is needed to dismantle the current “rape culture,” which currently makes it difficult for victims to report sexual crimes, achieve justice, and recover from their trauma. • Abuse experienced earlier in the lifespan predicts a higher likelihood of abuse in older adulthood. It is important to avoid siloed, reductionistic approaches to abuse, and to develop and implement more inclusive approaches to intervention that encompass all older persons, communities, and systems. • Interventions for elder abuse are not well developed and future research is needed to develop global public health strategies to elder abuse that target the social conditions and underlying determinants of elder abuse and culturally sensitive responses to the needs of communities. Such second-generation approaches will help to support all older persons in their goals to achieve full realization of the right to health and freedom from all forms of abuse, neglect, and violence.

Summary and Conclusion The primary goals for future directions in interpersonal violence and abuse interventions are to stimulate and initiate a nationwide movement to support training and research on various forms of such intervention programs, notably, child abuse and neglect victims and offenders, BIPs and interventions for victims, sexual assault victims and offenders, and elder abuse victims and offenders. Hopefully these interventions can serve to alter the general public’s perception and response to these issues so as to realize that they are not only social and legal problems but also physical, mental, and public health problems that can be prevented and treated. Effective batterer intervention programming, the teaching of respectful and safe interpersonal relationship training, and the promotion of positive parenting can create a cultural change in our society. The goal is to embrace and encourage healthy family relationships, which can in turn sensitize our treatment of older adult populations. Thus far, research reveals that interpersonal violence affects the psychological well-being of victims, accelerates the progression of disease, reduces longevity, and undermines overall health among all persons. Rather than viewing each life stage as separate and distinct, it is important for researchers, practitioners, advocates, and policymakers to utilize a life-span approach. Older adults who have been victimized by abuse must be able to participate in exploration and implementation of prevention policies and innovative responses of the justice system. Research examining coping strategies and treatment protocols that incorporate gender- and age-based perspectives must be prioritized. To create effective intervention policies, it is critical to have effective tools that proactively identify at-risk youth, vulnerable domestic partners, and multiple offenders. A more comprehensive and detailed understanding of the causes and consequences of interpersonal violence is needed in order to build a foundation for future research and intervention efforts.

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Cross-References ▶ Adult Sex Offenders Against Children: Etiology, Typologies, Investigation, Treatment, Monitoring, and Recidivism ▶ Adverse Childhood Experiences: Past, Present, and Future ▶ Best Available Evidence for Preventing Intimate Partner Violence Across the Life Span ▶ Caregiving and Elder Abuse: A Complex Relationship ▶ Corporal Punishment: Finding Effective Interventions ▶ Corporal Punishment: From Ancient History to Global Progress ▶ Correlations Among Childhood Abuse and Family Violence, Prevention, Assessment, and Treatment from a Trauma-Focused Perspective ▶ Couples Counseling to End Intimate Partner Violence ▶ Feminist Perspectives of Intimate Partner Violence and Abuse (IPV/A) ▶ Impact of Childhood Maltreatment and Polyvictimization on Adult Revictimization ▶ Implications of Maltreatment for Young Children ▶ Integration of the Types of Interpersonal Violence Across the Lifespan ▶ Intergenerational Transmission of Intimate Partner Violence: Summary and Current Research on Processes of Transmission ▶ Intersectionality and Intimate Partner Violence and Abuse: IPV and People with Disabilities ▶ Intersectionality of Elder Abuse and Mental Health Issues: Needs and Interventions for Victims ▶ Intersectionality of Race, Ethnicity, and Culture in Neglect, Abuse, and Violence Against Older Persons: Human Rights, Global Health, and Systems Approaches in Pandemics ▶ Interventions in the Aftermath of Sexual Violence: Justice, Advocacy, and Treatment ▶ Intimate Partner Violence in Later Life ▶ Introduction: Abuse in Later Life ▶ Masculinity and Violence Against Women from a Social-Ecological Perspective: Implications for Prevention ▶ Men Stopping Violence’s Definition of Male Sexual Violence Against Women: Implications for Prevention and Intervention ▶ Mental Health and Healthcare System Responses to Adolescent Maltreatment ▶ Military Sexual Trauma ▶ Mothers’ Perspectives on Abuse by Adult Children ▶ Neglect and Self-Neglect of Older Adults ▶ Parents Who Physically Abuse: Current Status and Future Directions ▶ Polyvictimization and Elder Abuse ▶ Protection Orders: Shielding Intimate Partner Violence Victims from Harm ▶ Psychological Maltreatment of Children and Youth: A Historical Perspective on the Right to Be Emotionally Safe ▶ Psychological Theories of Intimate Partner Violence

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▶ Recognizing the Trauma Experienced by Community-Dwelling Older Victims of Financial Abuse Perpetrated by Trusted Others ▶ Relationship Violence Perpetrator Intervention Programs: History and Models ▶ Sexual Victimization of the Elderly: An Examination of the Emergent Problem ▶ System Response to Intimate Partner Violence: Coordinated Community Response ▶ Systems Responses to Older Adult and Elder Abuse ▶ The Contemporary Study of Adult Survivors of Interpersonal Violence and the Development of Mental Health Treatment ▶ The Efficacy of Psychosocial Interventions for Partner Violent Individuals ▶ The Etiology of Child Neglect and a Guide to Addressing the Problem ▶ The Nature of Neglect and Its Consequences ▶ Wartime Sexual Violence: A Historical Review of the Law, Theory, and Prevention of Sexual Violence in Conflict

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Understanding Advocacy in Interpersonal Violence: A Brief Overview . . . . . . . . . . . . . . . . . . . . . . Advocacy is About Building Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Advocacy Is Transferring Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Advocacy as Transformation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Advocacy in the Gender-Based Violence Field: A Case Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . Building Advocacy Interventions from the Individual to the Community: A Brief History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A Move Towards Systems Advocacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Developing Engagement with the Criminal and Civil Legal Systems . . . . . . . . . . . . . . . . . . . . Expanded Engagement with Child Protective Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Professionalizing and Funding of the Movement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Radical Visioning for the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Culturally Specific Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Transformative Justice Advocacy Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Develop Community-Based, Survivor-Led Advocacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Invest in a Practice of Advocacy for Primary Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Advocacy is fundamental to all aspects of interpersonal violence. Many communities want to significantly change oppressive social conditions for survivors, especially women, girls, and trans and nonbinary femmes. Advocacy is the individual, interpersonal, community, and system-level strategies that stakeholders engage to transform conditions for those who are the most disenfranchised. As its core, advocacy is visionary work. It requires that communities see past current realities and dream about new ways of being. Therefore, determining the future of advocacy is inevitably a question about what needs to be envisioned to radically transform society. How should social conditions change, who needs to be a part of creating change, and what practical steps are needed to get there? What rights have not been actualized for communities who are deeply impacted by interpersonal violence, and what might be seen, felt, and heard when communities are able to fully exercise these rights? The purpose of this chapter is twofold. The first is to provide a brief overview of advocacy in the interpersonal violence movement; and the second is to propose possibilities to engage advocacy that centers survivors with histories of multiple marginalization and disenfranchisement. We will discuss how expanding notions and boundaries of support, meaningfully incorporating intersectionality into practice, and letting communities lead the work contributes to a radical visioning which can guide future advocacy efforts. Keywords

Advocacy · Interpersonal violence · Transformation · Survivors · Intimate partner violence · Sexual violence

Introduction Interpersonal violence encompasses multiple types of violence enacted in many types of relationships; yet is distinguished from other forms of violence because it describes how individuals perpetrate violence in order to exert power and control over another person. Much of what the United States knows about various forms of interpersonal violence – sexual assault and rape, child sexual abuse, intimate partner violence, stalking, child maltreatment, elder abuse, teen dating violence, sexual harassment, and youth violence – exist because of advocacy. Community-based prevention and intervention services, federal policies, coordinated social systems, and dedicated research funding started as dreams of a dedicated few. Advocacy efforts by those known and unknown created the current realities of the field, and while the interpersonal violence movement is imperfect, none of it would exist without advocacy. Advocacy increases possibilities for more people, and at its core is visionary work. The purpose of this chapter is to articulate a vision for advocacy in the field of interpersonal violence. Advocacy includes the individual, interpersonal, community,

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and system-level strategies that stakeholders engage to transform social conditions from oppressive and disempowering to into highly resourced and equitable. Advocacy seeks to ensure that communities who experience exploitation, disempowerment, marginalization, disenfranchisement, and violence achieve full human dignity. Advocacy can occur at multiple levels, ranging from the self to the system (Nichols 2019; Sullivan and Goodman 2019). Individual advocacy is employed to change the circumstances of one person, such as providing immediate crisis resources to a survivor. Interpersonal advocacy focuses on changing the relationships that directly or indirectly influence individuals lives. For example, a housing advocate may develop a close relationship with landlords in their community in order to leverage those relationships to provide survivors’ housing. Community advocacy are strategies or practices that can change conditions bounded by geography, ideology, or identity. This could include organizing protests or community education. Any attempt to change the culture, policies, processes, practices, or procedures within a single institution or across multiple institutions is systems advocacy. Systems advocacy has resulted in mandatory arrests policies of people who cause harm or placing sexual assault nurse examiners in hospital emergency rooms. This level of advocacy aims to improve how systems respond to survivors. At each of these levels, advocacy generates more resources, options, compassion, and knowledge in order to improve survivors’ lives. This chapter begins with a brief description of the shared components of advocacy: relationship building, transferring of knowledge and resources, and transformation. A brief synthesis of advocacy in the intimate partner and sexual violence fields follows. We then highlight the complicated lessons learned from the intensive, multilevel advocacy within these two movements that can inform future advocacy efforts. The chapter concludes with a description of three advocacy approaches that are currently being practiced by communities or have not yet been professionalized or entered into the mainstream movements but provide fertile ground to guide action.

Understanding Advocacy in Interpersonal Violence: A Brief Overview Advocacy in the interpersonal violence field seeks to attenuate social inequities by increasing power and providing access to resources for survivors (Costello and Durfee 2019). Advocacy goes beyond individual case management and is distinct from philanthropy. Across the diversity of studies and definitions, advocacy often contains three distinct components: meaningful relationship building, a transfer of resources, and an investment in transformation.

Advocacy is About Building Relationships Advocacy is a highly relational construct. In order to engage in effective advocacy, advocates must be aware of their social positionality (who they are and where their power is situated), an analysis of the major stakeholders (who holds power in the

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system and how that power influences survivors’ experiences), and how to develop relationships that can leverage power to create more equitable conditions for survivors. A good awareness of context also informs advocacy. A clear understanding of the histories, policies, stakeholders, cultures, and personal stories related to a social issue provides advocates with a foundation to build trusting and meaningful relationships with survivors. Advocates are often identified in the interpersonal violence literature as someone who is paid by a local social service organization to work on behalf of a survivor who is attempting to access a particular system or set of systems (e.g., courts, housing). An advocate is expected to spend intensive and dedicated time, ranging from 12 hours to 40 hours, to develop meaningful relationships with survivors (Rivas et al. 2016). Advocates may also accompany survivors who have to navigate difficult institutions or systems. Survivors can work with advocates to develop a safety plan with to mitigate future threats of violence from thier abusive partners (Costello and Durfee 2019; Sullivan and Goodman 2019; Johnson et al. 2014). Advocates who work directly with survivors develop a complex set of relational skills driven by values of being trauma-informed, survivor-driven, and culturally responsive (Sullivan and Goodman 2019). Good advocates recognize interpersonal violence as a form of trauma that must be acknowledged while they simultaneously work to meet survivors’ needs. Survivors’ needs, not advocate’s desires, become paramount in these relationships. Advocates become trustworthy through deep and compassionate listening and offering resources that align with survivors’ direct needs. An exceptional advocate understands the structural inequalities that creates needs and engages in reducing survivors’ self-blame and raising their critical consciousness of inequity. Advocates rely on meaningful relationship building to know what community resources need to be mobilized to increase survivors’ options (Sullivan and Goodman 2019). While building with survivors, interpersonal violence advocates simultaneously develop close relationships with community partners to leverage and increase resources for survivors (Nichols 2019; Sullivan and Goodman 2019). For example, advocates across multiple studies have reported that they specifically have relationships with critical stakeholders in the legal system (i.e., police, judges, lawyers) in an effort to enhance safety for survivors. The focus on building meaningful relationships creates and sustains pathways in the community that have the potential to make survivors’ lives become more resourced and hopeful (Houston-Kolnik et al. 2020; Johnson et al. 2014; Nichols 2019).

Advocacy Is Transferring Resources The transfer and acquisition of resources, broadly defined, is a critical component of advocacy. Research often describes this transfer between advocate and survivor as unidirectional, within a bounded period of time, and often related to knowledge and provision of referrals to community or governmental agencies. For example,

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advocates often provide information on how to navigate a complex system in order to reach an ideal desired outcome (Rivas et al. 2016). Some advocacy specifically focuses on skill transfer. Nichols (2019) described how legal advocates taught survivors how to properly document their partners’ stalking behaviors in order for the evidence to be admissible in courts (Nichols 2019). This practice was intended to help survivors learn how to validate their own experience and create evidence that can be an advocacy tool. Co-creating evidence with survivors is a common type of resource knowledge transfer within community-based participatory research methods (Ghanbarpour et al. 2018; Pk 2018). Some scholars have identified research as a form of advocacy because it increases the capacities of survivors to identify issues they want to address in their communities and provide them with the tools to respond. Ghanbarpour et al. (2018) describe essential components to building evidence with survivors as leads and coresearchers: “1) language justice, 2) trauma informed, 3) research justice, 4) acknowledging histories, 5) establish co-created principles, 6) maintain community autonomy, 6) apply an equity frame, 7) scaffold capacity building on community strengths and bidirectional learning, and 8) value community partners researcher skills.” Each principle holds the same core aims that underlie advocacy: to attenuate inequities and enhance resources, understand of history and context, focus on interdependence and shared learning, and create more socially just outcomes (Ghanbarpour et al. 2018). Knowledge transfer as advocacy also occurs when advocates seek to educate community members about interpersonal violence. These strategies can be formal and informal. Formally, organizations provide training and technical assistance to different social systems that impact survivors’ lives and simultaneously engage in prevention strategies with young people teaching healthy relationships (Johnson et al. 2014). Conversations that occur during social events such as parties or on online social media platforms are informal. Yet, all formal and informal advocacy efforts seek to reframe the social issue and generate more compassion and resources for survivors (Houston-Kolnik et al. 2020; Raphael et al. 2019).

Advocacy as Transformation The primary purpose of building relationships and transferring resources is to transform oppressive conditions. Advocates expect to create changes in survivors, the communities where they live, and the systems they engage. Survivors will have greater access to power and acquire resources to meet thier basic needs. Individual advocacy has improved survivors’ quality of life, supported their wellbeing, and increased feelings of safety (Rivas et al. 2016). Some organizations seek to change the community’s opinion on interpersonal violence through artsbased advocacy like documentary film screenings, mural making or political advocacy such as lobbying, protesting, or engaging in community debates (Christofides et al. 2018). At the systems level, advocacy is often synonymous with policy. While individual advocacy interventions have demonstrated limited

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impact on reduction of violence, large-scale systems efforts have resulted in increased public awareness and contributed to reduced rates of interpersonal violence (Raphael et al. 2019; White et al. 2019)

Advocacy in the Gender-Based Violence Field: A Case Example Some of the most notable strides in the interpersonal violence field have been within the sexual and intimate partner violence fields. In the United States, advocates engaged in multilevel strategies in order to interrupt and reduce violence across multiple communities. For sake of brevity in the following sections, we collectively refer to the sexual and intimate partner violence fields as the gender-based violence field. Since having a marginalized gender identity can further exacerbate or create disparate outcomes for survivors in all forms of interpersonal violence, we have decided to focus on these fields as a case example. We describe a brief history of these movements to highlight the lessons learned about engaging in multilevel advocacy and to use these lessons to underlie future advocacy efforts that are inclusive, community-based, and intersectional.

Building Advocacy Interventions from the Individual to the Community: A Brief History The gender-based violence field began as advocacy through informal networks of victim support, mutual aid projects and family caregiving. Survivors of violence have been connecting with one another for as long as surviving has existed. Many of the advocacy interventions now seen commonly in social services organizations began as volunteer and survivor community-led projects. For example, the DC Rape Crisis Center, one of the first and oldest rape crisis centers in the county, started in 1972 as an all-volunteer network of survivors using arts and theater, peer advocacy, and a hotline that operated from a survivor’s home. This self-advocacy kept survivors connected and able to build relationships with one another. Survivors found their way to one another through word of mouth, personal ads, and feminist publications before the Internet and MeToo Movement. In every community, survivors created hyper-local, culturally specific interventions to respond to interpersonal violence. As more survivors sought support from networks, organizations and collectives developed to meet the growing need of services – the rates of violence had not necessarily increased, yet people became more politicized and aware of the violence they experienced. From 1871 through the 1960s and 1970s, numerous laws were created. These laws included the ability to issue civil protection orders which moved domestic violence from inside the home to a national conversation that fueled the Battered Women’s Movement, the origin of many victim service organizations. These organizations and networks, most developing directly out of the women’s liberation movement or the second wave feminist movement, often maintained explicitly

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feminist values and used a mutual aid approach – a peer to peer, nonhierarchical model of shared leadership, expertise, and resources. Concurrently, these organizations worked to shift patriarchy in all its forms in the public sphere. Advocates organized marches like “Take Back the Night” as early as 1975, to give survivors of sexual violence a space to speak out about their experience. Advocates rallied, passed out fliers, and conducted public disruption. They also began conducting a type of community advocacy, later called community education, to prevent interpersonal violence. Today, community education programs specifically work with men on “toxic masculinity,” engage children in programming to help them understand their bodies, teach consent and healthy boundaries, conduct training for parents on how to recognize abuse, and training for the public about bystander intervention.

A Move Towards Systems Advocacy Yet, these interventions were generally community specific and hyper-local. As advocates began to petition their local and state governments for changes to legislation that would protect survivors, they soon understood that legislation could be varied state-by-state, confusing survivors and often allowing people who have done harm to evade accountability by simply crossing state lines. Laws were quickly being passed to protect survivors in more progressive states. However, in other communities, survivors had a harder time accessing services and finding safety. Laws around sexual assault and domestic violence were inconsistent, statutory rape laws varied, and in many communities, marital rape laws were nonexistent. From the time of the first law prohibiting a husband to rape his wife in 1977, it took 16 years for every state to outlaw marital rape. Though across states, the laws protecting same sex couples and the severity of the penalties varied. Advocates and organizers knew that in order to get the wide scale, systemic change they sought for all survivors, no matter which state they lived in, they needed to engage in federal legislative systems advocacy. Advocates began to formalize their work and build national coalitions centered on issues such as child protection, elder protection, domestic violence, and sexual assault. Due to their collective advocacy, congress held listening sessions to hear from survivors and advocates about the needs of survivors across the country. In response, the first federal legislation on interpersonal violence was passed. The Family Violence Prevention Act (FVPSA) became the first federal funding, in 1984, specifically dedicated to emergency shelter and supportive services for survivors of domestic violence and their children. Though focused on support for intimate partner violence, in subsequent reauthorizations, it was expanded to include teen dating violence, and interacts with other federal legislation including Child Abuse Prevention and Treatment Act (CAPTA), The Violence Against Women Act (VAWA), and the Elder Justice Act (EJA). Congress also passed the Victims of Crime Act (VOCA) of 1984. VOCA was created to compensate victims of interpersonal violence for costs incurred while surviving. While there is no price tag on the experience of violence, survivors often experienced severe economic

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hardship as a result of loss of job, moving for safety reasons, and medical costs. VOCA sought to mitigate some of those costs. In 1994, Congress passed landmark legislation, the Violence Against Women Act (VAWA). It was considered a victory for the violence against women movement (Goldscheid 2015). VAWA required that criminal legal responses coordinate with social services and federal funding. VAWA also required the federal government to publicly acknowledged interpersonal violence as a public health issue and crime and set federal standards for how these types of violence should be prosecuted. However, VAWA was not standalone legislation designed to protect survivors. VAWA was rolled into a larger suite of bills: the Violent Crime Control and Law Enforcement Act, commonly known as the Crime Bill, a bill often understood to expand militaristic policing, mass incarceration, and punitive responses to genderbased violence. In direct service organizations providing individual advocacy for survivors of interpersonal violence, the need for funding, housing, and supportive services was increasing. As a result, the simultanous need for state intervention and foundation support also began, deteriorating the foundational and core beliefs of many of these organizations. They began to move further and further away from liberatory, mutual aid models to adaptations of nonprofit hierarchy (Lehrner and Allen 2009). In order to assert their own legitimacy, these collectives of survivors began formalizing themselves. Several things occurred synchronously with mixed results: organizations deepened their engagement with police and criminal legal systems, expanded engagement with Child Protective Services and Family Service agencies, increased professionalization of the work and dependence on state funding (Richie 2012).

Developing Engagement with the Criminal and Civil Legal Systems Early on in the work to interrupt interpersonal violence, survivor collectives typically worked out of homes, local YWCAs, and sometimes churches and other civic agencies. They had little interaction with police, and courts were not yet prosecuting this form of violence. This caused rape crisis centers and domestic violence shelters to create solutions and interventions for violence that existed outside of most state institutions. Instead, they relied on informal networks to connect survivors to services and housing. With the expansion of legislation to protect survivors of interpersonal violence and a “tough on crime” approach, many of these organizations became complicit with, and in many instances, advocated for increased policing tactics with the intention of keeping survivors safe. In order to ensure that survivors had access to things like crime victim’s compensation and orders of protection, those survivors typically needed to file criminal charges against the person abusing them. Further, in some communities, prosecutors’ offices created “no drop” rules, for survivors who may have expressed fear or reluctance to carry through in a criminal case against their abuser. These no-drop or pro-prosecution policies ensured that prosecutors could follow through prosecution of an abuser without the survivor’s request or consent if they had evidence beyond a reasonable

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doubt (National District Attorneys Association Women Prosecutors Section 2017). Given the dynamics of domestic violence, and the risk of leaving, it seems survivors are making a rational choice about their own safety when deciding when and how to engage in criminal legal systems. The state continuing to prosecute without a survivor’s consent in the name of “public safety” proves what many prison abolition activists believe; prosecution is often for the benefit of the state, and not survivor centered. It is punitive and not restorative or transformative. These policies have shown to be quite dangerous for many survivors and impossible for some. For many survivors, particularly survivors of color, immigrant survivors, LGBTQIA survivors and marginalized survivors, police and courts have historically not been seen as a beacon of safety or protection. Due to the longstanding relationship between historically marginalized communities and police and other state institutions, many survivors’ express reluctance about engaging with them. Marginalized survivors often describe fears of: increased policing in their communities, deportation, not being believed by police, dual arrest, and police violence. Each of these fears disproportionately harms communities of color (Sherman 2016). These fears are warranted. In 2017, police murdered Charleena Lyles after she called to receive help for a burglary. Although police knew that she was a survivor of domestic violence and had history of mental health concerns; they used excessive force ultimately taking her life. Police sexual violence is the second-most reported form of police violence after use of excessive force (Ritchie 2017). In addition, police are not exempt from enacting domestic violence within their own families and communities. Given the widespread violence enacted by police institutions, many activists call for a divestment in engaging with these systems all together, and instead, an investment of other forms of safety and accountability practices. The Alliance for Safety and Justice, a community-based nonprofit in California conducted a quantitative study examining how victims viewed safety and justice. They found that the majority of people who have been harmed, including survivors of the most violent acts, want rehabilitation and behavior change for the people who caused harm, not jail (Alliance for Safety and Justice 2017). While VAWA allowed for greater prosecution of violence against women, it also expanded the role of criminal legal systems in the lives of survivors, particularly survivors of color. VAWA created mandatory arrest policies and expanded dual arrests, giving police the authority to arrest both parties if they could not determine the primary aggressor (Sherman 2016). Mandatory arrests began innocuously enough. They were created in response to police historically leaving the scene after attending a domestic violence call and essentially telling the couple to “just tone it down.” This left survivors at risk of increased violence, and death at the hands of abusers, as calling for help or attempting to leave frequently escalates the severity and lethality of violence. However, the effort to treat domestic violence with more seriousness had detrimental and traumatic effects for women of color, girls of color, and LGBTQIA survivors. Women of color, particularly Black and Latina women already experience damaging stereotypes and biases that led to poor services and care within these systems, which also made the likelihood of dual arrest more realistic (Sherman and

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Harris 2015). In New York, for example, 70% of the women affected by mandatory arrest or dual arrest policies were Black or Latina (Jacobs 2017). Embedded beliefs that Latinas are “hot-tempered,” and that Black women are “angry” and strong, often prevents them from being seen as victims in the public eye and the eyes of the law. Further, it leads to disproportionate prosecution of women of color for defending themselves against abusers, leading to arrest and even imprisonment for survivors who practiced self-defense such as the cases of Cyntoia Brown, Jacqueline Dixon, Pamela Smith, and Marissa Alexander. In LGBTQIA cases of partner violence, 26% of female same-sex cases and 27% of male same-sex cases resulted in dual arrests, compared to only 0.8% with male offenders and female victims, and 3% with female offenders and male victims (National Coalition of Anti-Violence Programs 2010). There is less data for trans and nonbinary survivors due to misgendering, and inconsistent record keeping. Additionally, because of heteronormative beliefs about LGBTQIA relationships, police may believe that “it’s just a catfight,” that both partners share equal responsibility in the violence or that the partner who presents as more “masculine” is the abuser. In response to the lack of consistency, the discrimination, and biases in police practices, many domestic violence shelters and sexual assault crisis centers began training police officers with funding through the Department of Justice STOP Violence Against Women Formula Grant Program which came directly out of VAWA legislation. Many programs also worked closely with police on local sexual assault response teams, and domestic violence task forces. This entanglement further solidified the connection between social service agencies and criminal legal systems. Though the US Department of Justice Bureau of Justice Statistics data shows that since 1994, the rates of domestic violence have fallen, those numbers only include cases in which a partner is arrested and convicted. However, advocates know that these types of violence are underreported, and the risk of arrest and deportation makes survivors even more reluctant to call for help from the police (Coker et al. 2015). From Black Lives Matter to activists working to pass the “Walking While Trans” bill, survivors are drawing the connections between state and interpersonal violence and demanding alternatives to policing for the long-term safety of survivors. Survivors are also asking the field to see the bias and violence in policing not as a few bad apples, but as historical and presently harming Black, Indigenous, and people of color. For survivors of color there is no separation between interpersonal violence and state violence, and for many, the relationship between social service agencies, police and criminal legal systems, is a manifestation of that reality.

Expanded Engagement with Child Protective Services Some research has estimated conservatively that at least 10–20% of children are exposed to intimate partner violence annually, with as many as one-third exposed at some point during childhood or adolescence (Carlson 2000). Further, child sexual abuse affects children at an alarming rate. Approximately 1 in 4 girls and 1 in 6 boys

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will experience sexual abuse before the age of 18. These data often exclude statistics that describe the experiences of child sexual abuse for transgender and gender nonconforming and nonbinary youth. The primary state intervention for children’s experiences of abuse lies in the hands of child welfare or child protective service agencies. Child protection began much like other variations of social services in the United States. Led by community members, much of our historical understanding of a child welfare system was overseen by small nongovernmental agencies and churches. Even in its earliest iterations, informal child welfare services often targeted and surveilled newly arrived immigrants, poor people, survivors of domestic violence (rather than the abusers), and Black people (Schene 1998). However, in many communities, child protection was communal. Many children of color were raised by family members other than their parents, including aunts, grandparents, and “play cousins;” their parents may have migrated or immigrated for work, either by moving to or from the United States or as was common during Jim Crow, families moved from the rural South to the industrializing North for better opportunities or to flee the domestic terrorism of white supremacist groups like the Ku Klux Klan. However, since its inception, the formalized child welfare system has been seen by Black and Indigenous people in particular as a gatekeeper, and a state institution with the power to disrupt family systems. The child welfare system is more likely to intervene in the lives and families of Black people is rooted in racist and sexist practices (Hill 2004). In many ways, social services can act as an intermediary agent of social control. Social workers and other direct service providers within these systems determine who receives services and what kind, they determine family separation, and can act as influencers within criminal legal cases. Multiple reports cite varying reasons for the disproportionate rate of Black families’ engagement with child welfare. The most common is that because Black families are more likely to live in poverty, and poverty is a major indicator of family services intervention, their children are more likely to interface with these systems. Others have been more explicit at naming the racism and bias across the life cycle of encounters these systems (Font et al. 2012). At every interaction from: the reporting phone call, to the provision of services, to investigation and the removal of children from the home, racialized bias influences decision-making. Mothers of color and survivors of domestic violence are often judged more harshly, their circumstances individualized as personal failings instead of viewed within the context of historical oppression, mocked with ridicule of being “welfare queens” and seen as neglectful of their children for leaving children alone as they work multiple low-wage jobs, or attend meetings with social services (Myers 2008). Black women are more likely to be reported for child abuse and maltreatment than any other race. For example, a study based in Florida demonstrated that despite the similar rates of substance abuse among Black and white women, Black women were reported to child protective services at approximately 10 times the rate for white women, and poor women were more likely than others to be reported (Chasnoff et al. 1990).

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The passage of the Adoption and Safe Families Act (ASFA) in 1997 further entrenched disparities in engagement with the child welfare system and removal of children of color by the state by incentivizing adoption instead of funneling resources into keeping families together by providing housing, subsidies, and supportive services. While the intention of ASFA was to prevent children from remaining in foster care for indefinite amounts of time, the funds used to expedite adoption disproportionately removed Black children from their parents. From family separation during slavery, to Native American boarding schools and Japanese internment camps, the United States public systems has a long history or removing children of color from their parents. Domestic violence survivors of color are often caught in the crosshairs of these multiple systems including child welfare, the criminal legal system, and social services. Black women are more likely to experience homelessness, domestic violence, and evictions at an alarming rate (Desmond 2015), often putting them in touch with public service staff who then have the ability to police them with impunity. Advocacy to protect children was often racially coded with anti-Black racism and misogynoir, anti-black misogyny directed at Black women (Bailey and Trudy 2018) – on one hand, historically, Black women and women of color were most often the caretakers of white children, while they were also seen as unfit to raise their own. This is illuminated in the way survivors of interpersonal violence are penalized for what child welfare describes as child endangerment (Goodmark 2004). Survivors of domestic violence, especially survivors of color, experience disproportionate criminalization for the things they do to keep themselves and their children safe. Whether a survivor stays with an abuser in order to keep her children clothed, and housed, or leaves the abuser and faces homelessness, it seems, no choice is the right choice. Further, no choice is an easy choice for survivors.

Professionalizing and Funding of the Movement As the gender-based violence field moved from small, local collectives into formalized nonprofit structures, and as organizations began engaging in systems advocacy, and receiving state and philanthropic funding, these organizations moved away from their more radical roots (Lehrner and Allen 2009). As the state and philanthropy began to drive the strategies of intervention, the radical work of transforming systems became white-washed and tepid. The professionalization of the genderbased violence field has worked to gatekeep, pacify social change, and reify social control. The mainstream gender-based violence field has, in its effort to protect survivors from to violence of intimate partners, become complicit with policing and state violence as an inevitability. Professionals within these systems often act in conflict to other radical social justice movements, instead working as agents of the state. Leaders of local domestic violence shelters frequently share tension between a desire to push for progressive city or state policies, or to support the organizing demands of activists in their communities, yet not wanting to lose support of conservative lawmakers who have

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been champions for their shelter, or for some survivors. These shifts have dramatically decreased the kind of advocacy in which gender-based violence organizations engaged. With the injection of funding to provide critical emergency and long-term services to survivors, gender-based violence programs also began to develop new requirements for the types of skills and professional degrees staff needed to do their work. Interventions moved from being peer-led to requiring master’s degrees in social work and other comparable degrees, limiting the people who could do the work of supporting survivors, in a field that was historically led by impacted communities. Moreover, with the introduction of the war on drugs, welfare reform, and increased homelessness, domestic violence shelters were seeing clients who were living with multiple co-occurring needs including mental illnesses, substance use, and poverty. In order to meet the needs of survivors, many programs took a clinical, mental health approach to service provision. This “one-size-fits-all” approach to mental health service provision continues to marginalize survivors of color, survivors who are LGBTQIA, survivors with disabilities, immigrant survivors, and more, as it does not take into account the historical, political, cultural, and social context in which survivors live. As requirements of employees shifted, so did the face of the field. Today, the majority of leaders of mainstream local and national antiviolence organizations are white, despite the disproportionate impacts of violence of people of color, and the fact that, in most metropolitan cities in the United States, people of color and Indigenous survivors make up the majority of people seeking supportive services. Further, the gender violence field often recreated and continues to recreate harmful narratives about what survivors need, while centering the experiences of white, cisgender, heterosexual, middle class survivors. Under the guise of survivor services, organizations create ahistorical policies and do not consider the experiences of marginalized survivors. Without analysis of the ways in which colonization, the legacy of enslavement and other historic atrocities also shaped sexual and domestic violence in the United States, the work of antiviolence organizations is incomplete. This includes the complicity of white women in the oppression of Black women, Native women, and other women of color (Ruttenberg 1993). Organizational policies are also a reflection of this history of domination. Antiviolence programs frequently enact draconian, paternalistic rules and requirements which limit the types of survivors who can come into the programs, which kind of resources survivors receive and when survivors can be terminated from programs (Gregory et al. 2017). Mandated services have mostly fallen out of practice within mainstream antiviolence organizations, in favor of the empowerment model which asserts that survivors are the experts on their own lives and are navigating a complex set of decisions and social realities that the advocate may not fully understand. Therefore, it is the advocate’s job to offer nonjudgmental support and information without being leading or directive (Cattaneo and Goodman 2015). However, whether in theory or practice, some antiviolence organizations continue to create tight restrictions on survivor behavior which mirror the oppression that survivors experience with their abusers and in broader society; mandating

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counseling, support groups and parenting classes, policing food intake, making threats to take children away or engage with child protective services, not giving survivors opportunities to take on leadership within the organization because they disagree with policies, creating punitive curfews, engaging in pre- and postarrest jail diversion, pathologizing survivors’ decisions, conducting background checks on survivors, terminating survivors out of programs because of addictions, treating survivors as inherently criminal or untrustworthy.

Radical Visioning for the Future Given the context of this complex history, future advocacy efforts should promote long-standing strategies rooted in indigenous knowledge of the community (culturally specific services), grassroots and community-based accountability strategies that move away from punitive models and do not involve state intervention (transformative justice), make a shift back to the origins where those who are most impacted lead the work (survivor-centered, survivor-led), and focus on the engaging work that seeks to create conditions to start harm before it begins (primary prevention).

Culturally Specific Services In response to a need for supportive services that take into account survivors’ unique experiences based on race and culture, the federal Office on Violence Against Women created a set of grants specifically to enhance services to survivors from unserved, underserved and inadequately served populations in 2005 corresponding to the reauthorization of VAWA. Advocates and survivors demanded increased access to services for Native survivors and survivors of color through the allotment of funding into community-led services. The importance of culturally specific services cannot be understated in future advocacy efforts. Survivors are more likely to reach out to an organization which is familiar with their culture, language, religion, or lived experience. Furthermore, because of the history of women of color interfacing with state institutions, such as child welfare and police, women of color may be distrustful of agencies whose staff reflect the communities with historical institutional power. Yet, because of professionalization of the field, overwhelmingly, in many metropolitan cities, white women were providing services to women of color as social workers, advocates, and case managers. It is important to note that culturally specific services is not a new concept though the language has emerged more recently. Early on in antiviolence movements, survivors of color acknowledged that their experiences were different than that of white women, their concerns about safety were different, and that healing looked different. Further, communities of color have always found ways, both informally and formally (through sororities, religious institutions, civic groups) to heal and support one another. Many grassroots antiviolence organizations led by communities of color and Indigenous communities lean into collective caretaking, practices that

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center interdependence instead of independence, building community networks, reducing organizational hierarchy rooted in dominance, and healing grounded in ancestral knowledge, body, earth, movement, and song. Culturally specific services interrupt patterns of domination by ensuring that survivors from marginalized communities see themselves not only as service recipients but also within leadership roles within these organizations, and at all levels of service provision and decision-making, from case managers, organizers, to ultimately, change agents. What differentiates culturally specific services from organizations that may serve a majority of a particular population is: • Who is in leadership and has decision-making power; is the board, advisory council, organizational leadership a reflection of the community being served? • What is the level of integration of culturally specific practices: What kinds of services are provided and do they meet the stated needs of survivors within the community? Is culture an afterthought (for example, merely translating documents into multiple languages or creating content that resonates with particular communities)? How are religious, dietary, cultural, musical, norms, healing practices integrated in a culturally specific way? • Who is being served: Do community members identify the organization as culturally specific, and does the community make up a majority of the people receiving services? Not every organization will be culturally specific, though all antiviolence organizations should strive to be culturally responsive and actively anti-racist and decolonial.

Transformative Justice Advocacy Approach Historically, the anti-violence field has been punitive in their approach to responding to interpersonal violence. Punitive justice centers “crime and punishment” rather than healing and transformation. For example, no-drop rules give prosecutors authority to move forward with cases where the survivor did not consent or has chosen not to participate in the process. The state is seen as the victim, and punishments that are predetermined and may or may not meet the needs of the survivor are doled out without survivor buy-in. This disempowering approach puts the onus on survivors to offer proof yet removes their ability to consent or make decisions about their versions of justice and accountability. Further, it removes people who cause harm from the community with little chance for their own rehabilitation and often disproportionately targets people who are already marginalized, leading to high recidivism rates. Finally, punitive approaches are often part of the driving factors for marginalized survivors’ reluctance to engage with criminal legal systems and the social service agencies which scaffold them. Many survivors express concern at prison systems and are reticent to engage in a system that further criminalizes their own communities.

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Transformative justice is an alternative to punitive models of accountability defined and implemented by the state. Advocacy within these practices are centered on how to respond to violence in ways that acknowledge the complex history of the harm doer and seek to transform the root cause that caused the harm to happen in the first place. Mingus (2019) describes as involving three distinct tenants: “1) do not rely on the state, 2) do not reinforce or perpetuate violence such as oppressive norms or vigilantism, and 3) actively cultivate the things we know prevent violence such as healing, accountability, resilience, and safety for all involved.” These options are designed and practiced with those who needed more choices and resources than mainstream options are able to provide survivors who experience multiple forms of marginalization and stigmatization.

Develop Community-Based, Survivor-Led Advocacy Recently, experts in the interpersonal violence field described what was needed to advance the field. They stated that the future was in the community, and researchers must intentionally work to understand communities’ priorities. They recommended the use of research methods that identify, highlight, and utilize community strengths, such as community-based participatory research. One expert stated that the natural first responders were community members and should be trained to mitigate violence. They also recommended building more ways to increase community engagement and trust between systems and community members, especially those systems that have negative histories (White et al. 2019). All of these ideas connect to an overarching understanding that communities are at the center of the work. This collective understanding from both practitioners and researchers is needed to mitigate and eradicate current violence and prevent future violence. While listening directly to communities about what they need to move forward provides critical expertise to the field; more is needed. Survivors from communities should lead the efforts as lobbyists, researchers, directors, and speakers. They need to guide the conversation, rather than just inform it. Most of the available information on advocacy is focused on paid advocates doing something on behalf of survivors; it is less common to understand how survivors are developing skills to advocate on their own behalf, especially at levels higher than the individual. Survivors are likely to engage in self-advocacy often (especially those who are unable to access traditional supports), but this form of advocacy is understudied (Crann and Barata 2019). One study of survivors using self-advocacy showed that many attended community speaking events, volunteered at organizations, and used social media to advocate on behalf of themselves and other survivors (Murray et al. 2015). Survivors have made vital contributions to advocacy and will continue to do so. Survivors have a unique vantage point on interpersonal violence and have the right to be at the tables that focus on making major decisions about their lives (Murray et al. 2015). This requires multiple organizations who engage in advocacy to shift from who they may believe is qualified to do the work based on professional degrees

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to prioritizing listening to those with lived experience and who demonstrate the relevant skills. It also requires a shift in the overall cultural mindset that survivors have agency. Advocates are not saviors and survivors are not simply service recipients. One strategy putting this into practice is creating advisory groups that center decision-making power for survivors. Another strategy is to develop projects and studies that make survivors research leads and center these groups as coprincipal investigators with full engagement in conceptualization and implementation. It would also mean engaging in survivor-led organizing within communities. These strategies put nonprofits in the background, rather than the foreground. Survivor led advocacy would also require a deep investment in the development of survivors to enhance thier leadership skills across their diverse communities, rather than be tokenized or exploited from their stories.

Invest in a Practice of Advocacy for Primary Prevention Early community and system-level advocates in the interpersonal violence field understood that in order to decrease prevalence rates, the culture, laws, and norms needed to shift. This belief was the impetus of prevention. The aim of primary prevention is to interrupt the thoughts, norms, cultural messages, and behaviors that allow or encourage violence. Primary prevention includes the education, training, and public awareness campaigns that are done before an individual act of violence has occurred and may be directed at universal audiences or select audiences. It is important to note that the audience for prevention is typically directed at the group of people most likely to commit harm. Risk reduction or risk mitigation strategies and supporting survivors after a harm has occurred are not primary prevention. Primary prevention may come in the form of: Bystander intervention trainings which teach community members how to spot aggressive behaviors and how to intervene nonviolently in interrupting harm; Training which promotes consent and nurturance culture in schools, universities, and other locations; Support which mobilizes men, boys, and masculine identified people as allies to help interrupt gender-based violence and; Public awareness campaigns which raise consciousness about the prevalence of violence, work to shift behaviors, offer tools and resources. Currently, there is not a specific national number of victim service organizations that provide individual advocacy and implement primary prevention activities such as community education. However, anecdotally, prevention programs are often underresourced and deprioritized in order to provide the life-saving services which respond to survivors’ immediate crisis needs. Programs such as Men Can Stop Rape, A Call to Men, and ReThink Masculinity explicitly address the role of “toxic masculinity” which refers to the “sociallyconstructed attitudes that describe the masculine gender role as violent, unemotional, sexually aggressive” in perpetuating gender-based violence against all genders. These programs seek to utilize a social ecological model to intervene before violence occurs by addressing risk factors at the individual level. Individual level risk factors can include having a history of abuse or misusing substances. At the community

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level, risk factors for interpersonal violence include poverty, housing instability, and unemployment. In order to prevent interpersonal violence at the community level, programs utilize a holistic approach which connects multiple disciplines and issue areas and resist working in silos. Collaboration between housing, healthcare, employment, social determinants of health, education, and community planning are necessary to ensure safety for communities. In additions to these factors, programs addressing masculinity also work at the community and macrolevel in order to shift the narrative about gender norms. The overall goal of primary prevention is to create a culture that does not rely on domination, control, and abuse.

Key Points • Advocacy is a multilevel construct that occurs at the individual, interpersonal, community, and systems level. • Three distinct components of advocacy include meaningful relationship building, transferring valuable resources, and investing in transformation. • Meaningful relationship building includes building with the survivor and the community in order to best support and resource survivors. • Transferring knowledge to survivors and communities provides opportunities to inform and reframe the social problem, as well as generate more sources for survivors. • The intimate partner and sexual violence fields began with grassroots, survivorled individual and community advocacy efforts that led to larger systems level advocacy. • While advocacy with the criminal legal, civil legal, and child protection systems resulted in a greater awareness of interpersonal violence and development of larger accountability systems, there were also iatrogenic impacts on communities with histories of marginalization and oppression. • The professionalization of the intimate partner and sexual violence movements led to practices within these movements that differed significantly from the original purpose and intent of the movement, leading to the development of disparaging and harmful service practices that disproportionately impact multiply marginalized survivors. • Future advocacy efforts should engage culturally specific advocacy efforts, transformative justice approaches to abuser accountability and survivor advocacy, and the development of efforts developed and led by survivors.

Summary and Conclusion Advocacy remains a critical source for the interpersonal field to build power and transform systems. Despite the types and variations, the emphasis on developing deep relationships, mobilizing resources, and engaging in ways to bring multilevel change provides a clear foundation on ways to move forward in this work. The future

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of advocacy ultimately requires a divestment in systems and practices that historically harm and decenter survivors of color and a meaningful investment in localized, community-based strategies that promote the leadership of the survivors.

Cross-References ▶ Advocacy and Intimate Partner Violence ▶ Fundamentals of Understanding Interpersonal Violence and Abuse

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Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child Trauma and Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Quantifying Child Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Addressing Child Abuse Through Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Modernizing Child Abuse Treatment and Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interpersonal Violence on College Campuses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Policies to Address IPV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gun Violence/Community Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hate-Based Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hate Crime Statistics Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Matthew Shepard and James Byrd Jr. Hate Crimes Prevention Act . . . . . . . . . . . . . . . . . . . . . . . Emerging and Future Policy Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Elder Justice Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. D. Elmore Borbon (*) Policy Program, UCLA-Duke University National Center for Child Traumatic Stress, Washington, DC, USA e-mail: [email protected] E. M. Tant Policy Program, UCLA-Duke University National Center for Child Traumatic Stress, Durham, NC, USA e-mail: [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_97

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Abstract

Violence and trauma are critically important public policy issues with few settings or systems immune from their impact. These important national challenges cross the boundaries of public health, healthcare, law enforcement, education, social services, and the justice system, among others. Recognizing the important role of both violence and trauma in the USA, policymakers have taken critical steps aimed at improving the national public policy response. These include policies to support data collection, protect survivors, fund prevention efforts, and assist in the aftermath of traumatic events. While much effort has been made in recent decades to address violence and trauma through public policy, much remains to be accomplished. This chapter will examine the policy landscape of violence and trauma across the lifespan in the USA, identify key advances and challenges, and outline future policy directions across several broad categories, including child abuse and trauma, intimate partner violence, community and gun violence, hate-based violence, and elder abuse. Keywords

Child trauma · Interpersonal violence · Community violence · Gun violence · Hate-based violence · Elder abuse · Public policy

Introduction Violence and trauma across the lifespan are pervasive and serious public health problems in the USA and around the world (Magruder et al. 2017). Estimates suggest that nearly 90% of the US population has experienced one traumatic event, while many more have experienced multiple events (Kilpatrick et al. 2013). Such traumatic events can include physical or sexual assault, death of a loved one due to violence, disasters, accidents/fires, exposure to hazardous chemicals, threat or injury to family or a close friend, combat or war, and witnessing traumatic events to others. Such exposure can have significant consequences for many survivors, including post-traumatic stress, depression, anxiety, and a variety of related physical and mental health sequelae. Over the last several decades, significant investments have been made in the scientific understanding of violence and traumatic stress. In addition, important strides have occurred in increasing public awareness regarding trauma, investing in prevention, and developing and disseminating trauma-informed treatments and interventions for the sequelae of trauma. As the fields of science and clinical practice in violence and trauma have advanced, so have efforts to establish and implement trauma-informed public policies. This chapter will focus on some of the important public policy efforts in the USA to address violence and trauma across the lifespan, among diverse populations, and across trauma types at the national level. Key advances and challenges will be identified. The trauma policy topics highlighted include child trauma and violence,

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interpersonal violence, community and gun violence, hate-based violence, and elder abuse. In addition, we offer some ideas for future directions in policy development in each of these areas.

Child Trauma and Violence Child abuse, neglect, and trauma are widespread issues that affect individuals at an early, critical stage in the lifespan. The Federal government outlines some parameters defining child abuse and neglect; however, it is left up to individual States to define and enforce child abuse laws (Child Welfare Information Gateway 2019b). According to the Federal government, child abuse is defined as “any recent act or failure to act on the part of a parent or caregiver that results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act that presents an imminent risk of serious harm” (U.S. Department of Health and Human Services 2020). Many victims of child abuse experience multiple forms of abuse and neglect resulting in complex trauma that begins during the developmental period of childhood and, if untreated, can have effects that can continue across the lifespan (Thompson et al. 2004; U.S. Department of Health and Human Services 2020). For example, victims of child abuse are more likely to experience a range of negative outcomes, including substance abuse, depression, anxiety, academic problems, reduced immune functioning, and even suicide (D’Elia et al. 2018; Prangnell et al. 2020). Here we will discuss child abuse and trauma broadly with the understanding that cases are typically complex and their impacts are far-reaching. Child abuse is an important policy issue because it impacts some of our most vulnerable citizens, robbing society of nascent lives and inflicting trauma on children who grow up to become adults with trauma histories and accompanying consequences. We will also discuss how the complexity of child abuse creates challenges for policymakers and law enforcement, as well as for researchers attempting to collect data and quantify its societal impacts.

Quantifying Child Abuse In 2018, there were 678,000 reported victims of child abuse in the USA, representing a slight, but steady increase from previous years (U.S. Department of Health and Human Services 2020). That same year, an estimated 1,770 children died because of child abuse and neglect, although experts agree that the actual number of deaths is likely higher (U.S. Department of Health and Human Services 2020). Quantifying the true impact of child abuse has proven challenging for several reasons. Prevalence and economic data are lacking in part because child abuse often hides in plain sight, making it difficult to adequately identify and measure in concrete policy terms. Reporting mechanisms are also insufficient to capture all child abuse cases, and the negative outcomes associated with abuse in early life are so complex and heterogeneous that they are challenging to predict and model. Despite inadequate data, we

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do know that long-term outcomes for victims of child abuse are compelling. Studies demonstrate that child abuse survivors are less likely to finish high school, attend college, and have steady employment compared to individuals who did not experience child abuse (Jaffee et al. 2018). Victims also experience significant negative physical and mental health outcomes, including increased risk of substance use disorders, depression, anxiety, infection, and death by suicide (D’Elia et al. 2018; Prangnell et al. 2020). These deleterious effects are further exacerbated among racial and ethnic minority children. Further, research in the past decade has demonstrated the intersectionality of various socioeconomic factors that increase the risk of child abuse among children who identify with multiple minority groups. The primary mechanism for the collection of child abuse data is the National Child Abuse and Neglect Data System (NCANDS) that relies on states to voluntarily report data (D’Elia et al. 2018). The NCANDS was established through the Child Abuse Prevention and Treatment Act (CAPTA), discussed in more detail later. Results from the NCANDS database are published and presented to Congress annually in a series of child maltreatment reports (Children’s Bureau 2015). With reports dating back to 1991, these data provide a benchmark for tracking trends in child abuse and neglect over time. Despite being a long-standing source of data, the NCANDS is not comprehensive. The Government Accountability Office (GAO) outlined shortfalls of the NCANDS, including, most notably, its heavy reliance on Child Protective Services (CPS) reports in many states. According to the GAO, relying only on CPS reports omits child maltreatment deaths for cases where children have had no interaction with CPS, which may represent a significant number of child deaths each year. Critics also note that NCANDS fails to capture incidents of near fatalities, which could provide key information to aid prevention (Government Accountability Office 2011). Another pertinent data collection instrument is the National Survey of Children’s Exposure to Violence (NatSCEV) administered by the Office of Juvenile Justice and Delinquency Prevention in collaboration with the US Centers for Disease Control and Prevention. Completed in 2008, the breadth of the NatSCEV covered all types of violence exposure for children up to 17 years of age, with specific questions asking about child maltreatment, including physical assault or injury, psychological or emotional abuse, neglect, and abduction. Results from the 2008 survey indicate a high level of overall violence exposure among American youth, with 61% of respondents disclosing exposure to any form of violence in the past 12 months. Specifically, 10% of NatSCEV respondents reported exposure to child maltreatment in the prior year. Parents or caregivers completed the survey on behalf of children under 9 years of age, which may have led to an underreported incidence of child maltreatment. The survey was only administered once, making it a useful snapshot; however, repeating the survey would allow for comparison of violence exposure, including child maltreatment, across time (Finkelhor et al. 2009). Data are lacking to give policymakers a robust and accurate picture of child abuse occurrence; however, research and tracking to date have elucidated trends that put children at higher risk of child abuse and neglect. For example, we know that poverty is highly associated with an increase in rates of child abuse (U.S. Advisory Board

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on Child Abuse and Neglect 1993). Continued attention must also be paid to the intersectionality among poverty and other factors, including race, ethnicity, gender, sexual orientation and other dimensions of culture and identity. Better understanding these factors that precipitate child abuse would allow policymakers to make greater investments in policies that assist high-risk populations and implement child abuse prevention, focused support for families, and treatment in cases where prevention fails.

Addressing Child Abuse Through Policy The US Department of Health and Human Services is responsible for defining and providing oversight of child abuse policies at the national level. States, however, have authority to enact their own legislation to address child abuse at the local level, including defining child abuse and neglect in civil and criminal statutes (Child Welfare Information Gateway 2019b). States also vary in how they choose to centralize and operate their child welfare systems, which are tasked with handling child abuse cases. Some states choose to operate a centralized state-administered child welfare system, whereas others disperse authority to local counties, or combine State and county level authority through a hybrid system (Child Welfare Information Gateway 2018). Among the laws that differ by state is the legal mandate to report suspected child abuse. In some States, anyone with a reasonable suspicion of child abuse is required to report to State authorities, whereas in other States only specific categories of individuals must report, such as school and medical personnel.

Child Abuse Prevention and Treatment Act (CAPTA) First enacted in 1974, the Child Abuse Prevention and Treatment Act (CAPTA) provides States with funding and guidance to support the prevention, assessment, investigation, prosecution, and treatment of child abuse (Child Welfare Information Gateway 2019a). CAPTA also set the standard definition of child abuse at the Federal level and established the Office of Child Abuse and Neglect and the Board on Child Abuse and Neglect to ensure that the provisions of CAPTA are carried out. CAPTA has been reauthorized numerous times, most recently in 2019 with total budget appropriations of more than $25 million dispersed across States, the District of Columbia, and Puerto Rico (Children’s Bureau 2012a). In 2015, the Act was reauthorized with updated definitions of child abuse, neglect, and sexual abuse that include victims of trafficking (Child Welfare Information Gateway 2019a). Other updates have included provisions to tackle the opioid epidemic. Children’s Justice Act and CAPE In conjunction with CAPTA, the Children’s Justice Act (CJA) and subsequent Child Abuse Prevention and Enforcement (CAPE) Act make funds available to States and US territories to assist in the handling of child abuse cases, with a particular sensitivity to child trauma. States that are eligible for CAPTA funding may also receive CJA and CAPE funds to train personnel, including law enforcement,

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healthcare, child protective services, mental health, and judicial staff; bolster child advocacy efforts; establish and support child fatality review teams; and reform judicial processes and laws to better support victims of child abuse (Children’s Bureau 2012b).

Family First Act of 2018 In 2018, lawmakers passed the Family First Act in an attempt to keep families intact and lessen burdens on overtaxed foster care systems across the nation. Historically, funding the prevention of child abuse has been secondary to interventional funding, and as noted by the US Advisory Board on Child Abuse and Neglect, this has created perverse incentives to remove children from the home rather than bolster parenting skills and prevent maltreatment. Proponents of the Family First Act argue that this restructuring of resources is key to bolstering prevention efforts. Specifically, the Family First Act allows States to use resources to fund child abuse prevention, supports kinship (relative) care, allows Federal reimbursement for residential treatment services for children requiring specialized treatment, and allows States to offer services to older youth up to age 23 (Social Security Act of 1935 2018). Critics of the Family First Act, however, argue that not enough evidence is available to determine best practices for child abuse prevention (Hailes et al. 2019; Viswanathan et al. 2018).

Modernizing Child Abuse Treatment and Prevention As our society becomes more complex, more children will be at risk of experiencing child abuse and trauma. Parents, in particular, face ever-increasing societal demands, which can be displaced upon their dependent children. The USA, unlike most developed nations, lacks many basic infrastructure supports for families and children, including protections for missing work to care for children, adequate wages to house, feed, and otherwise provide for children, and support for single parents. All of this results in significant parental stress and less than ideal parent-child relationships, sometimes including child abuse. Additionally, parents with their own trauma histories often lack the support needed to heal and develop positive parenting behaviors to foster mental health in their own children. A more robust mental healthcare system would provide this needed mental health support and thus bolster the emotional and physical health of future generations of Americans. Proactive, rather than reactive, mental healthcare is gravely needed, including the teaching of positive parenting. Data also suggest that paid parental leave may reduce rates of both child abuse and intimate partner violence within families by promoting strong bonds between parent and child, reducing financial burdens, and reducing general stresses felt by parents of newborns (D’Inverno et al. 2018). CAPTA has been the foundation of child abuse legislation in the USA for nearly 50 years. Its numerous amendments have aimed to modernize the law as new child abuse challenges emerge. Despite CAPTA’s call for data collection, however, efforts to capture more robust data are needed to adequately quantify the impacts of child

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abuse and subsequently inform policy development. To remedy this dearth of data in the meantime, the mental health community would benefit from working in collaboration with economists and other interdisciplinary researchers to develop better ways of measuring the economic impacts of child abuse and trauma. Where data do exist, particularly related to groups at increased risk for child abuse, they should be used by policymakers to promote prevention and treatment initiatives among high-risk populations. High priority should be given to prevention programs and timely treatment. Treatment is most effective when provided as close to the event(s) of abuse as possible; however, even adult survivors of child abuse can benefit from mental health treatment, such as cognitive behavioral therapy later in life (Hailes et al. 2019). Policymakers should adequately fund mental health treatment, particularly for children, and ensure that adequate evidence-based mental health services are widely available. Given the diversity of how States define and respond to child abuse and neglect, States should work to create child welfare systems that are trauma-informed. This includes being informed about policies and practices that may retraumatize victims of child abuse, as well as the high risk of secondary traumatic stress among professionals who routinely work with survivors of extreme child abuse. Vicarious trauma is especially impactful for individuals with their own history of abuse or neglect, making them more vulnerable to the effects of secondary traumatic stress.

The National Child Traumatic Stress Network In 2000, Congress established the National Child Traumatic Stress Network (NCTSN) as part of the Children’s Health Act. This unique Federal initiative is focused on raising the standard of care and increasing access to services for children and families who experience or witness traumatic events. The NCTSN includes a nationwide network of frontline providers, researchers, family members, and national partners committed to improving care for children and moving scientific gains quickly into practice (NCTSN 2020). The NCTSN is administered by the Substance Abuse and Mental Health Services Administration (SAMHSA) within the US Department of Health and Human Services and is coordinated and led by the UCLA-Duke University National Center for Child Traumatic Stress. The NCTSN began with 17 funded grantees in 2001 and has grown to currently include 116 funded grantees and nearly 170 affiliate (formerly funded) centers and individuals working in hospitals, universities, and community-based programs in 43 states and the District of Columbia. NCTSN grantees and affiliates provide clinical services; develop and disseminate new treatments, interventions, and resources; provide education and training; collaborate with a variety of systems of care; engage in data collection and evaluation; and inform public policy and awareness efforts (NCTSN 2020). The NCTSN is different from other government sponsored initiatives in that it addresses a broad and diverse group of traumatic events that children and families are exposed to, rather than focusing on one particular trauma type (e.g., child abuse, disasters). NCTSN centers focus on topics including (but not limited to) physical, sexual, or psychological abuse and neglect (including family violence); natural and

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technological disasters; community violence, trafficking, or terrorism; sudden or violent loss of a loved one; substance use disorder (personal or familial); refugee and war experiences (including torture); serious accidents or life-threatening illness; and military family-related stressors (e.g., deployment, parental loss, or injury) (NCTSN 2020). Further, over the last 20 years, the NCTSN has helped to respond to significant national crises, including the terror attacks on 9/11; Hurricanes Katrina, Harvey, and Sandy; school shootings and mass violence events; the unaccompanied and separated immigrant children crisis; the COVID-19 pandemic; and issues of racial equity and justice. The establishment of this network by Federal policymakers and the sustained support for diverse grantees around the country over two decades has significantly elevated the state of trauma-informed care for children in the USA. NCTSN centers have not only developed and disseminated trauma-informed evidence-based treatments for children and families in their own hospitals, universities, and clinics but have also trained millions of providers and partners in the broader community. Among the many successes of the NCTSN, is infusing a trauma-informed approach across systems of care, including juvenile justice, schools, child welfare, and healthcare. Experts, advocates, and policymakers continue to call for sustaining and growing the NCTSN around the country. Such continued support and growth would allow for more children and families to access clinical services and more professionals around the country to be trained in evidence-based treatments and interventions, thus further raising the standard of child trauma care in the USA. Moreover, the cooperative and collaborative structure of the NCTSN is a helpful model for other national trauma and violence collaborations focused on other populations.

Intimate Partner Violence Intimate Partner Violence (IPV), also known as domestic violence, involves physical, sexual, or psychological harm or stalking by an intimate partner (Breiding et al. 2015). “Intimate partner” may include a current or former partner or spouse, or anyone who shares a child in common with the victim, or who has cohabitated with the victim (Breiding et al. 2015). IPV is a significant policy issue that affects millions of people in the USA, including individuals of all genders, races, ethnicities, religions, sexual orientations, and socioeconomic groups (Anasuri 2016). More than one-third of women and over one-quarter of men in the USA have experienced IPV, and IPV accounts for 15% of all violent crimes in the USA. Additionally, 1 in 3 female murder victims and 1 in 20 male murder victims are killed by an intimate partner. The incidence of IPV is most prevalent among women of multiple races and those who identify as American Indian or Alaska Native; those in low-income households; and women who identify as bisexual. When combined, these characteristics intersect to result in exponentially increased risk for IPV victimization, for example, among multiracial bisexual women with low income. Despite data that are difficult to track, experts conclude that IPV results in significant physical and

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psychological consequences, increases in healthcare costs, and 8 million lost days of paid work each year for survivors (National Coalition Against Domestic Violence n.d.). Victims of IPV also include children, although they are often unacknowledged, silent victims (Wang and Pannell 2019). Some children suffer direct injury due to IPV, while others are frightened and helpless witnesses of aggression against a parent or loved one. Data collected from the NCTSN indicate that child exposure to IPV is the second most frequently occurring trauma among children. Perpetrators of IPV are also known to commit child abuse at a higher rate compared to the general population, with an estimated 30–60% of IPV perpetrators also committing child abuse (National Domestic Violence Hotline n.d.-a). Similar to other forms of person-to-person violence, IPV data are difficult to track. Victims of IPV suffer physical harm, much of which is not treated or reported due to shame and fear of retaliation, as well as serious mental health outcomes. Undocumented immigrants also face significant barriers to reporting and seeking treatment for IPV due to fear of deportation and lack of knowledge regarding how to navigate service systems. Data collection efforts, such as the National Intimate Partner and Sexual Violence Survey (NISVS), were originally created for law enforcement to track and apprehend perpetrators. Because the dataset was not designed for policymakers, many key elements that would aid lawmaker decisions are not included in the NISVS (Breiding et al. 2015). Similarly, hospitals that serve victims of IPV typically do not track or report comprehensive data, but rather track only what is necessary to treat the immediate needs of patients in their care (Breiding et al. 2015).

Interpersonal Violence on College Campuses Data have emerged in the past decade to shed light on interpersonal violence as a widespread issue on America’s college campuses. Among college students, 20% will experience sexual assault, dating violence, or stalking during their college career (Anasuri 2016). Many student victims, however, will never report the incident (Prangnell et al. 2020). Lack of reporting is often due to fear, and in many cases may result from a lack of clarity around whether or not the incident qualified as IPV. IPV is most common among women ages 18–24, which directly coincides with typical college enrollment (National Domestic Violence Hotline n.d.-a). Other factors unique to college campuses are also fueling the rise in IPV, including increased social media use that makes it easier for perpetrators to track and target their victims. College students also often engage in behaviors that increase the risk of IPV, including substance use. Alcohol use, in particular, is on the rise on college campuses in the USA. National Survey of Drug Use and Health (NSDUH) data from 2017 show that 34.8% of college students reported binge drinking in the past month, which is associated with a higher rate of sexual aggression among both males and females (Shorey et al. 2011). Students are also more likely to become victims of sexual assault when under the influence of substances like alcohol.

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Numerous high-profile cases in the USA in the past decade have brought awareness to IPV on college campuses, prompting universities to examine their policies related to sexual assault. In general, however, many colleges and universities are ill prepared to adequately address sexual assault and other forms of IPVon campus. The issue straddles both school administration and law enforcement, and as critics are quick to point out, many of the legislative changes in the past decade seem to steer students toward on-campus mediation rather than toward law enforcement. These IPV and sexual assault policies are left largely up to the colleges and universities themselves, and interventions to reduce rates of assault on college campuses are largely targeted toward women, such as teaching women self-defense. Many critics have argued that teaching victims to defend themselves is not the best approach to reduce IPV on campuses; however, data collected on the effectiveness of interventions targeted toward men indicate that more research is needed to identify what truly works (Graham et al. 2019).

Policies to Address IPV Among the Federal policies to address IPV on college campuses is the Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act (Clery Act). Passed in 2014, the Clery Act aims to strengthen efforts to prevent and respond to interpersonal violence on college campuses. Named after a student victim at Lehigh University, the Clery Act requires all universities participating in Federal student financial aid programs to abide by regulations related to campus safety and reporting. These regulations require that college campuses annually report to employees and students the crime statistics for the prior 3 years and details about efforts made by the campus to improve safety (The Clery Center 2020). Title IX also contains provisions meant to address IPV, given that women are the most common victims of IPV on college campuses. It is important to note, however, that in response to high-profile sexual assault accusations there has been a recent advocacy movement arguing that new norms about sexual consent have gone too far and unfairly victimize men, who are most likely to be the accused. As new cultural norms are being forged, it is important for policies to keep up with national discourse and ensure that they are informed by scientific and clinical knowledge in the field of traumatic stress.

Violence Against Women Act Key legislation, entitled the Violence Against Women Act (VAWA), was enacted in 1994 and remains the landmark IPV law in the USA. A part of the Violent Crime Control and Law Enforcement Act, VAWA sought to unite the criminal justice system, social services, and nonprofit organizations to assist victims of domestic abuse (National Domestic Violence Hotline n.d.-b). The Act also mandated that arrests be made for all domestic violence calls, a mandate that was highly criticized and eventually deemphasized in the reauthorization in 2005. Critics of mandatory arrest policies note that arrests increase the rate of revictimization, often with subsequent violent events being more severe than the initial incident. Victims are

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also aware that the repercussions of reporting their abusive partner to law enforcement pose a significant risk to their physical safety and therefore are less likely to report abuse when the consequence is automatic arrest. Mandatory arrests also sometimes lead to victims being arrested because law enforcement is unable to determine who is at fault. A key provision of the Violence Against Women Act was the establishment of the National Domestic Violence Hotline in 1996. The Hotline is funded as a nonprofit entity through a grant from the Administration on Children, Youth and Families within the US Department of Health and Human Services. The Hotline also includes the National Teen Dating Abuse Helpline specifically created for teens ages 13–18 who are experiencing dating abuse. The hotline is available 24 hours a day, 7 days a week and provides support in over 200 languages to victims of interpersonal violence by connecting them to education, resources, and local referrals. Since its inception in 1996, the hotline has responded to over 3 million calls (National Domestic Violence Hotline n.d.-b). In 2018, the Hotline received 321,573 calls, as well as a large increase in the number of online contacts through their chat service. According to NDVH data, online chats increased 147% in 2018 compared to the previous year, signaling a significant shift in how victims of IPV choose to seek help. The shift to technology-based support, as well as a persistent shortfall of resources to serve victims, are important for policymakers to understand as they continue to work to support survivors of domestic violence (National Domestic Violence Hotline 2018). As mentioned previously, IPV affects people of all genders and sexual orientations. Despite VAWA covering all individuals who are victims of IPV, women remain the direct focus of the legislation. In 2013, VAWA was reauthorized under the Obama administration to further protect American Indian survivors and members of the LGBTQ community, but more effort is needed to ensure equal representation and protection (National Domestic Violence Hotline n.d.-b). VAWA should continue to be reauthorized, although at the time of writing this, it was stalled due to lawmaker disagreement, primarily about gun safety legislation. Some lawmakers would like VAWA to do more to protect victims by making it illegal for all domestic abusers to possess firearms by closing what is commonly known as the “boyfriend loophole.” Current law specifies that married or previously married partners with a history of domestic abuse are prohibited from purchasing firearms, whereas dating partners with the same violent history are not precluded from accessing firearms. Proponents of closing this loophole argue that it would do more to protect victims of IPV, while opponents reject the idea of further gun control legislation.

Future Policy Directions The ever-increasing reaches of technology create more opportunities for IPV to extend into the digital realm. This occurs through online stalking, digital harassment, exploitation, and crowd sourcing violence. As our technological lives continue to expand, policymakers and law enforcement must be proactive in their efforts to protect victims and enact policies that make it easier to report

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threats of violence. Technology also offers the possibility for law enforcement to proactively detect threats of violence, although these capabilities are in their infancy and yet to be fully realized. In order for technology to be fully harnessed for this purpose, funding must be designated to make it worthwhile for solutions to be developed and rolled out. The “Me Too” movement of the late 2010s has led to national discourse, increased awareness, and various legislative efforts to combat IPV. After several notable cases of alleged sexual abuse by men in authority positions, 15 States passed legislation to combat workplace sexual harassment and gender-based discrimination. Future efforts should realize that victims are represented across all sociodemographic groups, even though women make up the largest proportion of known cases. Women’s advocates also note that IPV is most prevalent among women of reproductive age and poses significant risk to a woman’s autonomy over reproductive health, including unwanted pregnancy and infection with sexually transmitted infections (National Domestic Violence Hotline n.d.-b). This remains true on college campuses in particular, warranting thoughtful, measured response from campus administrators and law enforcement working collaboratively. At the Federal level, experts and advocates agree that VAWA should continue to be reauthorized. The legislation contains crucial provisions to protect and support victims of IPV, and policymakers should seek to expand those protections as more data become available about risk factors and evidence-based prevention. Further, this Federal initiative should continue to find opportunities to expand prevention, early intervention, and treatment for survivors and their families. Limited VAWA funding over the years has made it challenging to expand services to include the full range of psychosocial resources that can assist in recovery and healing. Recent US healthcare reforms have focused on patient-centered care coordination, including increased use of wraparound services for at-risk individuals. Wraparound services are tailored services and supports for individuals and families that address their specific needs across settings, including healthcare, schools, justice and welfare systems, and psychological services. Lessons learned from early careintegration reforms should be harnessed to screen for, treat, and prevent IPV, especially for those at highest risk for victimization. Data indicate that IPV occurs in conjunction with various social, emotional, and economic stressors, meaning that interventions must also be multifaceted. Successful strategies will require broad support across government, healthcare, mental health, social services, and community organizations.

Gun Violence/Community Violence Any dialogue on the landscape of violence in modern-day America would be incomplete without a discussion of community violence, in particular gun violence. Community violence can be defined as exposure to intentional acts of interpersonal violence committed in public spaces by individuals who are not intimately related to

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the victim (NCTSN n.d.). Gun violence, in particular, has remained at the core of US policy discussions since the nation’s inception, and today the debate continues as strongly as ever. A 2019 government report estimates that gun violence costs the USA $229 billion each year (Joint Economic Committee 2019). According to the same report, in 2017 the rate of gun-related deaths in the USA exceeded those caused by motor-vehicle accidents. On average, more than 100 people are killed daily by firearms, including 5 children per day (Joint Economic Committee 2019). It is important to note, however, that not all gun violence ends in death. The majority of gun violence incidences are nonfatal and even fatal events carry the collateral damage of psychological trauma to surviving victims and witnesses. Gun violence disproportionately affects economically and socially disadvantaged populations, children, and teens of color, among whom gun violence is the leading cause of death. While it is critical to consider policies to address community violence and gun-related deaths in public spaces, self-inflicted death by suicide is also a key factor that policymakers must consider when enacting gun safety policies. Suicide by firearms claims more than 22,000 lives every year in the USA and is 8 times higher than firearm suicide rates in other high-income countries (Joint Economic Committee 2019). Data show that States with the highest numbers of gun ownership, including Alaska, Arkansas, Idaho, Montana, West Virginia, and Wyoming, report the highest suicide rates (Joint Economic Committee 2019). Similarly, individuals living in a home with a firearm are more likely to die from suicide than those who do not own a gun. As such, it is important to recognize that efforts to reduce gun violence should not unduly penalize the mentally ill. Data show that individuals suffering from mental illness are significantly more likely to injure themselves than others (Swanson et al. 2015). Mental health advocates argue that tying gun safety policy to mental illness would further stigmatize individuals seeking mental healthcare. Research and gun-related violence data are critically lacking in the USA. Over the last 20 years, Congress limited gun research through the Dickey Amendment that mandated no US Centers for Disease Control and Prevention funding could be used to advocate or promote gun control. In 2019, however, Congress passed its first spending bill that allocated funding for gun research. The nearly 20-year stalemate resulted in significant lack of evidence related to gun safety in the USA. Without data to fully understand the extent of gun ownership, precipitating factors that lead to gun violence, and environmental precursors, little progress can be made to curb the tide of gun-related injury and death. Gun violence is also a central element of the violence landscape in the USA, including intimate partner violence, suicide, and accidental death and injury from guns. More robust data gathering and analysis related to gun death, injury, and associated trauma are needed, including expansion of the National Violent Death Reporting System (NVDRS) and the National Incident-Based Report System (NIBRS). Once collected, these data should be shared with researchers, clinicians, and policymakers in a timely fashion to curb the tide of violence across the USA.

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Hate-Based Violence Violence motivated by hate and bias has a long-standing history in the USA. Currently, the Federal definition of a hate crime is a “criminal offense which is motivated, in whole or in part, by the offender’s bias(es) against a race, religion, disability, sexual orientation, ethnicity, gender, or gender identity” (Federal Bureau of Investigations 2020). This Federal definition has been expanded over time to include greater protection for a wider variety of at-risk groups. In recent years, the USA has experienced a disturbing number of reported hate-motivated crimes. Data from 2018 indicate that there were 7,036 single-bias incidents involving 8,646 victims (Federal Bureau of Investigations 2019). The majority of these crimes were motivated by race/ethnicity/ancestry bias (59.6%), while others were motivated by bias based on religion (18.7%), sexual orientation (16.7%), gender identity (2.2%), disability (2.1%), and gender (0.7%). Among these reported hate crimes in 2018 were 24 homicides and 22 rapes. In addition to the crimes reported against people, 2,641 property crimes and 289 actions classified as crimes against society were also reported (Federal Bureau of Investigations 2019). Research indicates that hate-based violence is intended to send a threatening message not only to the immediate victim but also to their entire community. Further, this type of violence and trauma may have broad and complex social consequences that affect individuals and larger subpopulations of society. Survivors can experience post-traumatic stress reactions, related psychological and physical challenges, and difficulty trusting in relationships and social institutions (Ghafoori et al. 2019). In 1968 the first Federal hate crime statute was signed into law, which made it a “crime to use, or threaten to use, force to willfully interfere with any person because of race, color, religion, or national origin” (U.S. Department of Justice 2019). Since then the significant social, economic, and psychological burden of such crimes has brought experts, advocates, and policymakers together to further develop policies in this area. Hate crime laws in the USA traditionally fall into two categories: those related to data collection and statistics and those related to prosecution of crimes. Below are some examples of Federal policies in both areas. Accurate data regarding the prevalence of hate-based violence in the USA has been difficult to obtain. Many challenges make accurate accounting difficult, including reluctance among survivors to report, limited hate crime education and training among local law enforcement, and poor coordination at the national level. In recent decades, important policy efforts have been enacted to improve hate crime data collection at the national level.

Hate Crime Statistics Act The Hate Crime Statistics Act, which was signed into law in April 1990, requires the collection of data “about crimes that manifest evidence of prejudice based on race, religion, sexual orientation, or ethnicity.” This landmark law and its subsequent

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amendments have helped to establish a reporting system to collect data on this important type of violence in the USA. There are two primary sources for hate crime data nationally, including the FBI Uniform Crime Reporting Program and the National Crime Victimization Survey. Although they use differing approaches, they both offer important information that helps in understanding hate crimes in the USA (U.S. Department of Justice 2020). In 2013, the Federal Bureau of Investigations Director further improved data collection efforts by approving an important recommendation of the Criminal Justice Information Services Advisory Policy Board. Specifically, this action expanded the Hate Crime Statistics Act to include seven new religions in the religion category and added an anti-Arab bias motivation provision (U.S. Department of Justice 2020). Such efforts to update and modernize hate crime reporting and data collection systems are critical to ensuring that national data most accurately represent the current status and scope of the problem.

Matthew Shepard and James Byrd Jr. Hate Crimes Prevention Act In addition to policies to collect data and report statistics, a key landmark policy related to hate-based violence prosecution was signed into law in 2009. The Matthew Shepard and James Byrd, Jr., Hate Crimes Prevention Act expanded the Federal hate crime definition, enhanced legal resources for prosecutors, and offered greater opportunities for Federal law enforcement to support State and local partners (U.S. Department of Justice 2019). The law added new protections against crimes based on gender, disability, gender identity, and sexual orientation. In addition, this law provided support and technical assistance to State, local, and tribal jurisdictions to assist in investigating and prosecuting hate crimes (U.S. Department of Justice 2018). Advocacy for passage of this legislation took many years and involved a broad coalition of policy champions, civil rights organizations, religious groups, disability rights advocates, social scientists and experts, and other key partners. Many of these groups have been active in assisting government with the effective implementation of this law over the last decade. Unquestionably, this critical Federal law helped to expand the at-risk groups that are now protected and to offer greater assistance and Federal resources to States and localities that may have limited prior experience with prosecuting hate crime cases.

Emerging and Future Policy Directions Although this chapter focuses on Federal policy initiatives, it is worth noting that States are also taking important policy steps on hate-based violence. Currently, hate crime laws have been enacted in 47 states, the District of Columbia, Puerto Rico, and the US Virgin Islands. While these State laws represent an important step forward, they vary in effectiveness, and many fail to cover crimes based on sexual orientation, gender, or gender identity (Center for the Study of Hate and Extremism 2019).

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A continued focus and investment in understanding and combatting hate-based violence is warranted in the US. Investments in tracking and better understanding troubling trends must continue, including a rise in white nationalist and homegrown terror groups, growing anti-immigrant sentiment, increasing anti-Semitism, and continued targeting of African Americans, Latinos, Muslim Americans, Asian Americans, and members of the LGBTQ community. Further, additional policy investments must be made to dismantle systemic and structural racism and discrimination, prevent hate-based violence before it occurs, and assist survivors in recovering from the physical and psychological wounds of such trauma. Scientists, experts, and advocates have much to contribute to the policy debates regarding Federal investments in prevention and assisting survivors and communities in healing in the aftermath of victimization.

Elder Abuse Older adulthood can be a time filled with many positive experiences; however, for some, later life is accompanied by experiences of abuse and exploitation. Current estimates suggest that nearly 1 in 10 people over age 60 are victims of abuse (U.S. Centers for Disease Control and Prevention 2019a). Elder abuse is “an intentional act, or failure to act, by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult” (U.S. Centers for Disease Control and Prevention 2019b). Such abuse can include physical abuse, sexual abuse or abusive sexual contact, emotional or psychological abuse, neglect, and financial abuse and exploitation. Physical and psychological abuse can have lasting effects on health and well-being. Further, estimates suggest that victims of elder financial abuse suffer devastating losses up to $3 billion annually in the USA (Blancato 2019). While many scientists, clinicians, aging experts, and advocates have worked diligently to raise awareness and advocate for action to address elder abuse, national policy solutions have been slow and hard fought. As referenced earlier, landmark Federal laws were established decades ago to address violence and abuse against women and children. However, the first large-scale law to address elder abuse, the Elder Justice Act, was more recently enacted as part of the Patient Protection and Affordable Care Act.

Elder Justice Act The Elder Justice Act became law in 2010. This policy represents the first comprehensive Federal law to address the abuse, neglect, and exploitation of older adults. Specifically, it authorized initiatives to coordinate the Federal response to elder abuse, promote elder justice research and innovation, support Adult Protective Services systems, and provide additional protections for older adults living in long-term care facilities (Administration for Community Living 2017).

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While passage of the Elder Justice Act was a critical step forward in preventing and intervening to address elder abuse, the establishment of the law was only a first step. Over the last 10 years since enactment, less than 10% of the authorized funding has been allocated to this Federal initiative. This is especially important for the primary provisions in the law related to dedicated funding for Adult Protective Services to focus on elder abuse (Blancato 2019). Further, other key provisions have never been funded, including one to create forensic centers to help in elder abuse detection. Key aging experts and advocates, including the Elder Justice Coalition, which worked for over 7 years to advocate for the enactment of the Elder Justice Act, have identified several barriers to full implementation of this law. These barriers include denial among policymakers about the prevalence of elder abuse, lack of reliable data on the problem, poor enforcement of laws already in place, and ageism (Blancato 2019). In addition, some have suggested that competition for resources exists between the advocates working on behalf of other violence prevention issues (e.g., domestic violence) (Blancato 2019). Further, additional Federal efforts are needed related to how we define and use the term elder abuse. Historically, inconsistent definitions for elder abuse have been used nationally, making it difficult to accurately determine the magnitude of the problem and inform prevention and intervention efforts (U.S. Centers for Disease Control and Prevention 2019b). Overall, elder abuse has lagged behind other forms of violence and trauma in securing key Federal policy support and resources. It is clear that elder abuse and other trauma types would benefit from a greater intergenerational approach to policy development, implementation, and advocacy.

Key Points • Violence and trauma are critically important public policy issues that affect individuals at all stages across the lifespan. • Despite some efforts to measure the impact of violence and trauma, robust data and statistics are lacking due to siloed data collection efforts and intrinsic difficulties in obtaining data. • Policymakers in the USA should continue to fund and reauthorize comprehensive research and interventions to address violence and trauma across the lifespan. • Given the multifactorial nature of violence in our society, policy solutions should encompass a wide array of services and supports, including healthcare, mental health, schools, social services, justice and welfare systems, and community organizations. • Attention must be paid to the most vulnerable victims of violence, particularly those who are less able to report and seek treatment on their own, including children, women, members of the LGBTQ community, racial and ethnic minorities, undocumented immigrants, and the economically disadvantaged.

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Summary and Conclusion Over the last 40 years, important scientific advances have occurred in the violence and traumatic stress fields. At the same time significant investments have been made in developing and disseminating many effective prevention, early intervention, and clinical treatments for survivors across the lifespan, their families, and communities. As noted above, Federal policies have helped to initiate and support some of these critical scientific and clinical successes. Although public awareness and recognition about violence and trauma has increased among policymakers, challenges remain ahead in preventing and addressing violence and trauma across the lifespan. Investments in critical Federal violence and trauma initiatives must continue and be strengthened. Key programs should be regularly debated, updated, and reauthorized in a timely manner without partisan rancor, and should focus on the needs of survivors along with scientific and clinical evidence. Previously authorized provisions in many of these enacted laws have gone unfunded or underfunded for far too long. Full implementation of these Federal initiatives could bring more comprehensive resources to these important public health challenges. Further, as the demographic makeup of the USA continues to change, policy investments should be responsive to increasing diversity, intersectionality, and populations at significant risk for trauma and violence. Finally, diverse experts and stakeholders should be regularly convened to determine next steps for advancing policies in the traumatic stress, violence prevention, and intervention fields. Special attention should be paid to avoiding duplication of existing policy initiatives that are effective and instead focus on supporting what works and identifying gaps and strategies that help to make the most significant improvements for the greatest number of survivors and communities.

Cross-References ▶ Hate Crimes: A Special Category of Victimization ▶ Overview of Child Maltreatment ▶ Systems Responses to Older Adult and Elder Abuse

References Administration for Community Living. (2017). The Elder Justice Act. Retrieved from https://acl. gov/about-acl/elder-justice-act Anasuri, S. (2016). Intimate partner violence on college campuses: An appraisal of emerging perspectives. Journal of Education and Human Development, 5(2), 74–86. https://doi.org/ 10.15640/jehd.v5n2a9.

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Future Directions in Interpersonal Violence Prevention Across the Lifespan

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Aliya R. Webermann and Christopher M. Murphy

Contents Introduction: What is Interpersonal Violence? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Preventing Multiple Forms of Violence Across The Lifespan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interpersonal Violence Rarely Occurs in Isolation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Promising Examples of Efforts to Prevent Multiple Forms of Violence . . . . . . . . . . . . . . . . . . Intervening at Multiple Levels of the Social Ecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Incorporate the Context of Violence into Prevention Programming . . . . . . . . . . . . . . . . . . . . . . . The Complex Interplay Between Various Levels of the Social Ecology . . . . . . . . . . . . . . . . . . . . . . The Importance of Selective and Indicated Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . An Example Prevention Program that Combines Universal, Selective, and Indicated Strategies: Triple P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . An Example of the Need for Selective and Indicated Prevention: Campus Sexual Assault . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Use of New and Emerging Technologies in Violence Prevention . . . . . . . . . . . . . . . . . . . . . . . . Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract

Exemplary programs from many parts of the world illustrate promising practices, critical challenges, and new opportunities for the future of interpersonal violence prevention. This chapter identifies several themes for the future, including the need for strategies that can prevent multiple overlapping forms of violence; the importance of mitigating violence risk at multiple levels of the social ecology;

This chapter was initially published with an incorrect copyright holder name. It has been corrected to © Springer Nature Switzerland AG. A. R. Webermann · C. M. Murphy (*) Department of Psychology, University of Maryland, Baltimore County, Baltimore, MD, USA e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2022 R. Geffner et al. (eds.), Handbook of Interpersonal Violence and Abuse Across the Lifespan, https://doi.org/10.1007/978-3-319-89999-2_99

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the unique value of selective and indicated prevention to disrupt emerging patterns of violence; and the exciting new opportunities for scalable prevention strategies using social media, content sharing, and mobile computing technologies. Future violence prevention efforts will benefit greatly from careful attention to the remarkable accomplishments to date of dedicated activists, practitioners, and researchers who have worked tirelessly to realize the fundamental human right of safety from interpersonal violence. Keywords

Interpersonal violence · Prevention · Child maltreatment · Intimate partner abuse · Sexual assault · Youth violence

Introduction: What is Interpersonal Violence? According to the National Partnership to End Interpersonal Violence Across the Lifespan (NPEIV), key examples of interpersonal violence (IPV) include the physical and sexual abuse of children, bullying, gang violence, intimate partner abuse, elder abuse, human trafficking, rape, sexual assault, and gun violence (NPEIV 2020). Scholars often distinguish interpersonal violence from state-sanctioned and political forms of violence such as war, civil war, genocide, police brutality, and mass incarceration. However, such distinctions are somewhat arbitrary. State-sanctioned violence often directly facilitates IPV, as exemplified by the systematic use of rape as an instrument of war. It also helps to create and sustain the ideologies and social structures that foster IPV, including the belief that “might makes right.” State-sanctioned violence maintains social systems that suppress human rights and safety for women, children, poor people, and for ethnic, racial, and religious minorities. By undermining the rule of law, police brutality and mass incarceration create social disorder and promote violence in disenfranchised communities (Leovy 2015). Safety from exposure to IPV is a fundamental human right, yet violence remains an endemic global public health problem. IPV disproportionally impacts youth, women, poor people, and racial, ethnic, and religious minority populations (Minority Rights Group International 2016; Smith et al. 2017; WHO 2016, 2017). Approximately 1 in 3 women worldwide experience physical and/or sexual violence (SV) in their lifetime (WHO 2017). Each year, approximately 1 billion children ages 2–17 experience physical, sexual, or emotional violence or neglect (Hillis et al. 2016), while 1 in 6 people aged 60 and older experience abuse within community settings (WHO 2018). An estimated 200,000 young people aged 10–29 are murdered each year, representing 43% of global homicides (WHO 2016). The detrimental effects of IPV vary depending on the nature and context of the exposure(s) and the victim’s developmental status. Negative consequences can include physical injuries, death, traumatic brain injury, chronic health problems, sexually transmitted infections, mental health issues (e.g., posttraumatic stress disorder, depression, substance use disorders), and impairments in academic and

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vocational functioning (Felitti et al. 1998; Smith et al. 2017; WHO 2016, 2017, 2018). The individual and population-level economic burdens of IPV are substantial. The estimated annual cost of substantiated US childhood abuse and neglect (CAN) cases is $428 billion, with lifetime individual victim costs of $830,928 for nonfatal childhood abuse cases and $16.6 million for fatal childhood abuse (Peterson et al. 2018a). The lifetime population-level burden for intimate partner abuse (IPA) in the USA is estimated at $3.6 trillion (Peterson et al. 2018b). These profound individual, community, and societal costs highlight the need for effective strategies to prevent IPV before it occurs through universal primary prevention efforts. In addition, increased efforts are needed to reduce violence among those at high risk (selective prevention) and to intervene in the early stages of perpetration and victimization to prevent subsequent violence (indicated prevention). Primary prevention of IPV has long been an emphasis of public health organizations such as the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC). Many dedicated researchers, practitioners, educators, and advocates have devoted their careers to this mission. Surprisingly, however, although many programs and approaches have been developed to prevent different forms of IPV, a much smaller number of programs have a strong empirical evidence base demonstrating violence prevention in controlled studies replicated across contexts (DeGue et al. 2014; Fortson et al. 2016; Rosen et al. 2019; Whitaker et al. 2013). This chapter provides an overview of future directions in IPV prevention, focusing on promising approaches, gaps in existing practice and research, and key conceptual and practical challenges. The brief format precludes coverage of the broad range of existing prevention approaches and therefore focuses on specific examples to elaborate key themes and future directions. Many of the examples reflect our scholarly focus on gender-based violence. We use ecological systems theory (Bronfenbrenner 1979) to identify multiple points for primary, selective, and indicated prevention across the lifespan in varied social and cultural contexts. The themes and priorities emphasized here are only a few among the myriad of critical issues in violence prevention. Specifically, one key theme is the need for strategies that can prevent multiple forms of violence across the lifespan, and the critical importance of assessing multiple forms of violence within prevention research and practice. A second key theme is the importance of transcending the common focus on individual- and microsystem-level change to mitigate violence risk at multiple levels of the social ecology. A third key theme involves the complex interplay between various levels of the social ecology. Notably, social and community norms can influence efforts to promote change at the individual and family level, producing highly variable effects of violence prevention efforts in different contexts. A fourth key theme involves the critical importance of selective and indicated prevention to disrupt emerging patterns and cycles of violence at key points in individual, family, and community development. The final key theme focuses on the potential for new media and communication technologies to revolutionize aspects of violence prevention.

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Preventing Multiple Forms of Violence Across The Lifespan Interpersonal Violence Rarely Occurs in Isolation Multiple forms of IPV are strongly interconnected. Notably, IPV exposure is an important developmental risk factor for subsequent IPV perpetration. For example, the developmental trajectory from exposure to family violence to perpetration of IPA has been supported in numerous longitudinal and retrospective studies (SmithMarek et al. 2015) and in many cultural contexts (e.g., Fulu et al. 2017). Similarly, youth engaged in gang-related violence often joined gangs in the first place to seek safety from bullies or abusive family situations (▶ Chap. 84, “Taking Stock of Gang Violence: An Overview of the Literature,” by M. Valasik and S. E. Reid, this volume). Studies of Adverse Childhood Experiences (ACE) demonstrate that child adversities, including CAN, are common and widespread. Exposure to CAN and other ACEs is linked to a wide range of negative physical and mental health outcomes, including increased risk for IPV. ACE exposures have been specifically linked to subsequent perpetration of IPA, SV, and adolescent aggression and conduct disorder (Tharp et al. 2013; Whitfield et al. 2003). Greater cumulative exposure to ACEs is associated with an increased number of health and behavioral problems (Felitti et al. 1998). Similarly, cumulative exposure to interpersonal trauma, especially CAN, is linked to greater posttraumatic symptoms (e.g., Briere et al. 2016). The effects of ACEs on subsequent violence appear to be explained, in part, by the mental health impacts of childhood adversity, including depression, anxiety, substance abuse, and PTSD (e.g., Mair et al. 2012). The evidence is clear and compelling that cumulative exposure to adversity, violence, and trauma in childhood is a common shared risk factor for multiple forms of IPV, operating through developmental pathways that involve problems with emotion regulation and impulse control. Strong interconnections are also found between perpetration of multiple forms of IPV. For example, young adolescents who bully peers are more likely to commit SV in later adolescence (Espelage et al. 2015a, b). Teens with high levels of aggression and conduct disorder are at increased risk for perpetrating IPA and SV in adulthood (Tharp et al. 2013). Belonging to a gang is also a consistent risk factor for SV perpetration (Tharp et al. 2013). Adults who engage in IPA have elevated rates of CAN perpetration (Appel and Holden 1998) and SV perpetration (Tharp et al. 2013). In fact, it is very difficult to identify any two forms of interpersonal violence that are not significantly and positively correlated with one another. The interconnections between multiple forms of IPV involve multiple pathways of influence. Critical examples include the detrimental impacts of CAN and other early forms of interpersonal victimization; shared individual-level risk factors including problems with emotion regulation and impulse control; bi-directional associations between intrafamilial violence and violence outside the home; and shared contextual risk factors including family instability, violent and delinquent peer networks, community crime and violence, limited vocational and educational opportunities, economic instability, and poor access to mental health care and

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substance abuse services (Wilkins et al. 2014). It is also important to note that specific forms of IPV have unique features, including specific risk factors, protective factors, and postvictimization outcomes. However, the evidence indicates that IPV rarely occurs in isolation, and risk factors that are common across multiple forms of violence often outweigh the influence of risk factors that are unique to specific forms of violence. It is therefore counterintuitive that most existing prevention efforts focus on only one form of IPV, rather than trying to mitigate risk for multiple forms of IPV.

Promising Examples of Efforts to Prevent Multiple Forms of Violence One example of a cross-cutting approach to prevent multiple forms of violence and reduce adjacent risk factors is home visiting programs such as the Nurse-Family Partnership (NFP) and Healthy Families America (HFA). Home visiting programs are intended to prevent CAN and promote maternal and child health among first-time mothers, low-income mothers, and families with other disadvantages. They typically target the time span from pregnancy to age 5. These programs have been shown to be efficacious in achieving these goals in a number of countries (Mejdoubi et al. 2015). Within the USA, both NFP and HFA have evidence of reducing CAN, and some research has also found reductions in other forms of IPV, including juvenile delinquency and IPA (Bair-Merritt et al. 2010, 2015). A wide range of early home visiting programs have been shown to increase protective factors that may reduce long-term risk for IPV. Benefits include increased positive parenting, reduced child maltreatment, and enhanced child development (Sama-Miller et a